CLM-2026-013166
Desert Heart Institute, Cardiology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Shirley Boyd
- Member ID
- UHC-95505-65
- Date of birth
- 1972-08-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-432068
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-7640
- Coverage period
- 2023-03-01 to present
- Deductible
- $565.58 of $1,000.0057%
- Out-of-pocket maximum
- $556.70 of $2,000.0028%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 5417959678
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- none / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $391.00 | $215.05 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1,2 | $7,959.00 | $4,377.45 | — | — | DeniedCO197 |
| Totals | $8,350.00 | $4,592.50 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-468292
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-025735 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-06: UNKNOWN (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-08-06 11:47
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-08-17 01:54
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-17 15:55
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-468292.pdf2 pages
Itemised statement totalling $8350.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000837 | 2026-09-08 | Pinecrest Regional Medical Center | $1,074.00 | Approved |
| CLM-2026-004686 | 2026-08-14 | Pinecrest Clinical Laboratories | $106.00 | Approved |
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
Precertification required and absent.