CLM-2026-014995
Northgate Heart Institute, Cardiology. Service 2026-08-26 at outpatient hospital (POS 22). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Carlos Weber
- Member ID
- UHC-41704-07
- Date of birth
- 1951-02-13
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-431967
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0197
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,729.68 of $3,500.0078%
- Out-of-pocket maximum
- $2,511.03 of $7,000.0036%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 7832141635
- Location
- Los Angeles, CA · TIN 48-8536899
- Authorisation / referral
- PA2026705944 / 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 | $4,899.00 | $2,694.45 | $1,347.56 | $1,346.89 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $382.00 | $210.10 | $63.03 | $147.07 | Paid |
| 3 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,346.00 | $740.30 | $222.09 | $518.21 | Paid |
| Totals | $6,627.00 | $3,644.85 | $1,632.68 | $2,012.17 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-965329
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-035150 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-26: CHOICE-PLUS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026705944 on file for 93458. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (1929886434). | |
| 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: Northgate Heart Institute2026-08-26 17:54
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026705944_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-26 to 2026-11-24.
- Itemized billitemized_PA-965329.pdf2 pages
Itemised statement totalling $6627.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030780 | 2026-09-11 | Heritage Rehabilitation Center | $180.00 | 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.