CLM-2026-014544
Desert Cardiovascular Associates, Cardiology. Service 2026-05-18 at outpatient hospital (POS 22). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Benjamin Thompson
- Member ID
- UHC-12484-48
- Date of birth
- 1992-01-19
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-414763
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2682
- Coverage period
- 2024-02-01 to 2026-02-25
- Deductible
- $11.45 of $500.002%
- Out-of-pocket maximum
- $127.18 of $2,000.006%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5097822972
- Network
- In network
- Rendering NPI
- 8039511554
- Location
- Mesa, AZ · TIN 54-0867004
- Authorisation / referral
- PA2025587229 / 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 | $9,146.00 | $5,030.30 | — | — | DeniedCO27 |
| Totals | $9,146.00 | $5,030.30 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-768161
- 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-012977 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-18 is after coverage terminated on 2026-02-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025587229 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (5097822972). | |
| 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 Cardiovascular Associates2026-05-18 11:56
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-24 00:29
Attachments
Documents received with the claim
- Prior auth letterPA2025587229_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-18 to 2026-08-16.
- Itemized billitemized_PA-768161.pdf5 pages
Itemised statement totalling $9146.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-18 is after coverage terminated on 2026-02-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000757 | 2026-07-24 | Northgate Reference Lab | $55.00 | Denied |
| CLM-2026-017879 | 2026-04-20 | Evergreen Family Practice | $376.00 | Denied |
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
Service after coverage termination.