Claims workbench/CLM-2026-013121

Institutional claim · UB-04 · EDI 837I

CLM-2026-013121

Desert Cardiovascular Associates, Cardiology. Service 2025-12-24 at outpatient hospital (POS 22). Received 2026-05-15.

Denied

Billed

$8,879.00

2 lines

Allowed

$4,883.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Maria Wallace
Member ID: UHC-98629-97
Date of birth: 1967-03-02
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-428109
Relationship: Child, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-8421
Coverage period: 2025-01-01 to present
Deductible: $919.48 of $1,500.0061%
Out-of-pocket maximum: $1,994.36 of $4,500.0044%
Copays: office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits: 8 of 20 used

Provider

Billing and rendering

Billing provider: Desert Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 5097822972
Network: In network
Rendering NPI: 6874745725
Location: Mesa, AZ · TIN 54-0867004
Authorisation / referral: PA2025632634 / 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	$8,287.00	$4,557.85	—	—	DeniedCO29
2	93015	Cardiovascular stress test	—	1	1,2	$592.00	$325.60	—	—	DeniedCO29
Totals						$8,879.00	$4,883.45	—	—

Diagnoses (ICD-10-CM)

1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
2. I10 Essential (primary) hypertension
3. I48.91 Unspecified atrial fibrillation

Claim header

Patient account: PA-838518
Frequency code: 1 (original)
Accident: No
DRG: 287
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-030814 (provisional, link confidence 1.00).
Eligibility	Pass		Active on 2025-12-24: CHOICE-PLUS-PPO (PPO), effective 2025-01-01.
Timely filing	Fail	CO29	Received 142 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 PA2025632634 on file for 93458.
Provider network	Pass		In-network provider Desert Cardiovascular Associates (5097822972).
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.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Desert Cardiovascular Associates2025-12-24 18:58
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
SystemSystem: Claims system2026-05-15 03:14
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-15 13:08
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025632634_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2025-12-24 to 2026-03-24.
Itemized billitemized_PA-838518.pdf3 pages
Itemised statement totalling $8879.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Timely filing: Received 142 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity