CLM-2026-014094
Summit Cardiovascular Associates, Cardiology. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Elizabeth Smith
- Member ID
- UHC-74794-15
- Date of birth
- 1980-06-08
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-407317
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group NULL
- Coverage period
- 2022-06-01 to present
- Deductible
- $417.66 of $1,000.0042%
- Out-of-pocket maximum
- $659.40 of $2,000.0033%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 3211365515
- Location
- Houston, TX · TIN 53-6389420
- Authorisation / referral
- PA2026686749 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,138.00 | $4,475.90 | $1,750.41 | $2,725.49 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,456.00 | $800.80 | $240.24 | $560.56 | Paid |
| Totals | $9,594.00 | $5,276.70 | $1,990.65 | $3,286.05 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-490381
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-010753 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-25: - (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026686749 on file for 93458. | |
| Provider network | Pass | In-network provider Summit Cardiovascular Associates (5138686964). | |
| 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 Cardiovascular Associates2026-01-25 15:51
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026686749_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-25 to 2026-04-25.
- Itemized billitemized_PA-490381.pdf6 pages
Itemised statement totalling $9594.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014095 | 2026-01-25 | Summit Cardiovascular Associates | $9,594.00 | Denied |
| CLM-2026-012410 | 2026-02-03 | Meadow Heart Institute | $431.00 | 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.