CLM-2026-014322
Lakeside Heart Institute, Cardiology. Service 2026-09-24 at outpatient hospital (POS 22). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Emily Adams
- Member ID
- UHC-15907-13
- Date of birth
- 2000-07-22
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-402109
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3252
- Coverage period
- 2022-09-01 to present
- Deductible
- $203.03 of $500.0041%
- Out-of-pocket maximum
- $207.86 of $1,500.0014%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8827628438
- Network
- In network
- Rendering NPI
- 6584145711
- Location
- Houston, TX · TIN 99-8948998
- 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 | $596.00 | $327.80 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1,2 | $9,100.00 | $5,005.00 | — | — | DeniedCO197 |
| Totals | $9,696.00 | $5,332.80 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-918798
- 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-045200 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-24: MEDICARE-ADV-A (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 8 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 Lakeside Heart Institute (8827628438). | |
| 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: Lakeside Heart Institute2026-09-24 15:53
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-02 01:31
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-918798.pdf8 pages
Itemised statement totalling $9696.00 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.