CLM-2026-013907
Valley Heart Institute, Cardiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Luis Greene
- Member ID
- UHC-14290-02
- Date of birth
- 2000-06-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409099
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7057
- Coverage period
- 2022-01-01 to present
- Deductible
- $992.20 of $2,500.0040%
- Out-of-pocket maximum
- $2,240.75 of $7,500.0030%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 7225141952
- Location
- Mesa, AZ · TIN 29-6624105
- Authorisation / referral
- PA2026551374 / 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 | $1,308.00 | $719.40 | $719.40 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1,2 | $8,194.00 | $4,506.70 | $1,903.89 | $2,602.81 | Paid |
| Totals | $9,502.00 | $5,226.10 | $2,623.29 | $2,602.81 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-305893
- 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-013801 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: MEDICARE-ADV-A (MA), effective 2022-01-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026551374 on file for 93458. | |
| 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 Institute2026-01-12 13:00
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026551374_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-01-12 to 2026-04-12.
- Itemized billitemized_PA-305893.pdf8 pages
Itemised statement totalling $9502.00 across 2 lines.
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-2026-032462 | 2026-05-26 | Canyon Reference Lab | $111.00 | Approved |
| CLM-2026-025318 | 2026-03-02 | Sunrise Cardiovascular Associates | $1,683.00 | Approved |
| CLM-2026-013908 | 2026-01-12 | Valley Heart Institute | $9,502.00 | Denied |
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.