CLM-2026-014209
Valley Heart Institute, Cardiology. Service 2026-01-26 at outpatient hospital (POS 22). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Barbara Marquez
- Member ID
- UHC-40992-91
- Date of birth
- 2002-02-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432741
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3713
- Coverage period
- 2023-04-01 to present
- Deductible
- $326.53 of $1,000.0033%
- Out-of-pocket maximum
- $424.21 of $2,000.0021%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 6980948338
- Location
- Atlanta, GA · TIN 70-2461607
- 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 | $628.00 | $345.40 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,092.00 | $3,350.60 | — | — | DeniedCO197 |
| Totals | $6,720.00 | $3,696.00 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-336499
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013399 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-B (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 21 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 (1412691184). | |
| 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 Institute2026-01-26 09:20
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-16 01:49
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-336499.pdf2 pages
Itemised statement totalling $6720.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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.