Claims workbench/CLM-2026-012882

Institutional claim · UB-04 · EDI 837I

CLM-2026-012882

Unity Cardiovascular Associates, Cardiology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-07-25.

Needs review

Billed

$8,912.00

2 lines

Allowed

$4,901.60

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Joyce Ryan
Member ID: UHC-02549-23
Date of birth: 2008-06-13
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-404381
Relationship: Spouse, Tampa, FL

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-2734
Coverage period: 2025-08-01 to present
Deductible: $1,547.63 of $3,500.0044%
Out-of-pocket maximum: $243.40 of $10,500.002%
Copays: office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Unity Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 3984509984
Network: In network
Rendering NPI: 6703760317
Location: Austin, TX · TIN 85-7157083
Authorisation / referral: PA2026899262 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	93458 rev 0481	Cardiac catheterisation, left heart	—	1	1	$7,542.00	$4,148.10	—	—	Review
2	93306 rev 0480	Echocardiogram, complete	—	1	1,2	$1,370.00	$753.50	—	—	Review
Totals						$8,912.00	$4,901.60	—	—

Diagnoses (ICD-10-CM)

1. I50.9 Heart failure, unspecifiedprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-758554
Frequency code: 1 (original)
Accident: No
DRG: 287
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-003224 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-06-14: CHOICE-PLUS-PPO (PPO), effective 2025-08-01.
Timely filing	Pass		Received 41 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026899262 on file for 93458.
Provider network	Pass		In-network provider Unity Cardiovascular Associates (3984509984).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Follow-up for heart failure, unspecified. Plan discussed, medications reconciled. Note dic”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Cardiovascular Associates2026-06-14 11:37
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-07-25 04:56
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-25 16:27
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2026899262_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-06-14 to 2026-09-12.
Itemized billitemized_PA-758554.pdf8 pages
Itemised statement totalling $8912.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Follow-up for heart failure, unspecified. Plan discussed, medications reconciled. Note dic”.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity