CLM-2026-014028
Unity Cardiovascular Associates, Cardiology. Service 2026-05-01 at outpatient hospital (POS 22). Received 2026-05-24.
Member
Resolved through the identity graph
- Member
- Sofia Weaver
- Member ID
- UHC-52569-74
- Date of birth
- 1995-10-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411781
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8793
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,178.81 of $1,500.0079%
- Out-of-pocket maximum
- $8.35 of $3,000.000%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 1172694162
- Location
- Nashville, TN · TIN 22-5957660
- 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 | $603.00 | $331.65 | $323.28 | $8.37 | Paid |
| Totals | $603.00 | $331.65 | $323.28 | $8.37 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-122057
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025171 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-01: MEDICARE-ADV-B (MA), effective 2025-09-01. | |
| Timely filing | Pass | Received 23 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 Unity Cardiovascular Associates (6971241222). | |
| 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: Unity Cardiovascular Associates2026-05-01 16:49
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-122057.pdf3 pages
Itemised statement totalling $603.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025359 | 2026-06-27 | Heritage Imaging Center | $3,174.00 | Denied |
| CLM-2026-014029 | 2026-05-01 | Pinecrest Cardiovascular Associates | $603.00 | Needs review |
| CLM-2026-011722 | 2026-03-21 | Northgate Medical Group | $380.00 | 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.