CLM-2026-014275
Desert Heart Institute, Cardiology. Service 2026-06-24 at outpatient hospital (POS 22). Received 2026-07-11.
Member
Resolved through the identity graph
- Member
- Brittany Jensen
- Member ID
- UHC-79140-14
- Date of birth
- 1944-03-11
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-418330
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-5448
- Coverage period
- 2023-01-01 to present
- Deductible
- $598.18 of $1,000.0060%
- Out-of-pocket maximum
- $582.46 of $3,000.0019%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 7207735847
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- PA2026127807 / 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 | $1,194.00 | $656.70 | $478.28 | $178.42 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,795.00 | $4,837.25 | $1,451.18 | $3,386.07 | Paid |
| Totals | $9,989.00 | $5,493.95 | $1,929.46 | $3,564.49 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-227192
- 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-026893 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-24: UNKNOWN (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026127807 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-06-24 12:44
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Prior auth letterPA2026127807_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-06-24 to 2026-09-22.
- Itemized billitemized_PA-227192.pdf4 pages
Itemised statement totalling $9989.00 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
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.