CLM-2026-014844
Summit Heart Institute, Cardiology. Service 2026-09-28 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Albert Alvarez
- Member ID
- UHC-42353-95
- Date of birth
- 1975-08-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416072
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7707
- Coverage period
- 2024-10-01 to present
- Deductible
- $568.87 of $1,000.0057%
- Out-of-pocket maximum
- $389.68 of $4,000.0010%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 7728787830
- Location
- Tampa, FL · TIN 24-2775289
- Authorisation / referral
- PA2025044198 / 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 | $1,504.00 | $827.20 | $549.95 | $277.25 | Paid |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 1 | $377.00 | $207.35 | $62.21 | $145.14 | Paid |
| 3 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $9,129.00 | $5,020.95 | $1,506.29 | $3,514.66 | Paid |
| Totals | $11,010.00 | $6,055.50 | $2,118.45 | $3,937.05 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-862455
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038704 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-28: MEDICARE-ADV-A (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025044198 on file for 93458. | |
| Provider network | Pass | In-network provider Summit Heart Institute (1318552993). | |
| 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: Summit Heart Institute2026-09-28 17:25
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025044198_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-09-28 to 2026-12-27.
- Itemized billitemized_PA-862455.pdf5 pages
Itemised statement totalling $11010.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014845 | 2026-09-28 | Summit Heart Institute | $11,010.00 | Denied |
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.