Claims workbench/CLM-2026-014095

Institutional claim · UB-04 · EDI 837I

CLM-2026-014095

Summit Cardiovascular Associates, Cardiology. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-03-26.

Denied

Billed

$9,594.00

2 lines

Allowed

$5,276.70

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

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 Associates
Cardiology · 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	—	—	DeniedCO18
2	93306 rev 0480	Echocardiogram, complete	—	1	1	$1,456.00	$800.80	—	—	DeniedCO18
Totals						$9,594.00	$5,276.70	—	—

Diagnoses (ICD-10-CM)

1. I50.9 Heart failure, unspecifiedprincipal
2. I25.10 Atherosclerotic heart disease of native coronary artery without angina

Claim header

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, 1 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 60 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-014094: same member, date of service, procedures and billing provider. Exact duplicate claim or service
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.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Cardiovascular Associates2026-01-25 12:42
Patient seen for heart failure, unspecified.
SystemSystem: Claims system2026-03-26 06:18
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

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.pdf8 pages
Itemised statement totalling $9594.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Duplicate check: Exact duplicate of CLM-2026-014094: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014094	2026-01-25	Summit Cardiovascular Associates	$9,594.00	Approved
CLM-2026-012410	2026-02-03	Meadow Heart Institute	$431.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity