CLM-2026-013092
Northgate Cardiovascular Associates, Cardiology. Service 2026-01-24 at outpatient hospital (POS 22). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Nicholas Adams
- Member ID
- UHC-35449-26
- Date of birth
- 1947-10-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418358
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8300
- Coverage period
- 2025-01-01 to present
- Deductible
- $950.30 of $1,500.0063%
- Out-of-pocket maximum
- $552.06 of $3,000.0018%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7788544188
- Network
- In network
- Rendering NPI
- 3810693721
- Location
- Denver, CO · TIN 90-6939418
- Authorisation / referral
- PA2025888542 / 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 | $7,517.00 | $4,134.35 | — | — | DeniedCO29 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,406.00 | $773.30 | — | — | DeniedCO29 |
| Totals | $8,923.00 | $4,907.65 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-239175
- 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-007596 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: NULL (PPO), effective 2025-01-01. | |
| Timely filing | Fail | CO29 | Received 201 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025888542 on file for 93458. | |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (7788544188). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Cardiovascular Associates2026-01-24 16:06
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-08-13 04:18
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-13 13:59
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025888542_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-24 to 2026-04-24.
- Itemized billitemized_PA-239175.pdf8 pages
Itemised statement totalling $8923.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 201 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.