CLM-2026-013612
Valley Heart Institute, Cardiology. Service 2026-01-16 at outpatient hospital (POS 22). Received 2026-02-14.
Member
Resolved through the identity graph
- Member
- Jacob Parker
- Member ID
- UHC-01644-25
- Date of birth
- 1969-11-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431263
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2023-12-01 to present
- Deductible
- $818.97 of $2,500.0033%
- Out-of-pocket maximum
- $4,665.50 of $10,000.0047%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 7654485151
- Location
- Mesa, AZ · TIN 29-6624105
- Authorisation / referral
- none / REF837781
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 | $5,097.00 | $2,803.35 | — | — | DeniedCO197 |
| Totals | $5,097.00 | $2,803.35 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-238490
- 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-007109 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-16: CORE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 29 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 Valley Heart Institute (9412184639). | |
| 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: Valley Heart Institute2026-01-16 18:19
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-14 03:28
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-238490.pdf8 pages
Itemised statement totalling $5097.00 across 1 line.
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-2026-018355 | 2026-05-26 | Lakeside Internal Medicine Associates | $235.00 | 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.