CLM-2026-013267
Summit Heart Institute, Cardiology. Service 2026-05-19 at outpatient hospital (POS 22). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Samuel Williamson
- Member ID
- UHC-39070-93
- Date of birth
- 1960-08-28
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-411582
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9790
- Coverage period
- 2025-10-01 to 2026-07-27
- Deductible
- $756.09 of $1,500.0050%
- Out-of-pocket maximum
- $913.46 of $3,000.0030%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 1779596984
- Location
- Tampa, FL · TIN 24-2775289
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,189.00 | $653.95 | $653.95 | $0.00 | Paid |
| Totals | $1,189.00 | $653.95 | $653.95 | $0.00 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-551908
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010091 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-19: MEDICARE-ADV-A (MA), effective 2025-10-01, terms 2026-07-27. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Heart Institute (1318552993). | |
| 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: Summit Heart Institute2026-05-19 17:41
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-551908.pdf9 pages
Itemised statement totalling $1189.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000078 | 2026-03-18 | Northgate Medical Group | $510.00 | Approved |
| CLM-2026-002474 | 2026-01-31 | Cornerstone Orthopedic Specialists | $174.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.