CLM-2026-015032
Northgate Cardiovascular Associates, Cardiology. Service 2026-07-31 at outpatient hospital (POS 22). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Roy Tucker
- Member ID
- UHC-34706-33
- Date of birth
- 1946-01-17
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-402916
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2083
- Coverage period
- 2022-12-01 to present
- Deductible
- $799.08 of $1,000.0080%
- Out-of-pocket maximum
- $587.38 of $4,000.0015%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7788544188
- Network
- In network
- Rendering NPI
- 3727655979
- Location
- Denver, CO · TIN 90-6939418
- 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 | $614.00 | $337.70 | $214.60 | $123.10 | Paid |
| Totals | $614.00 | $337.70 | $214.60 | $123.10 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-189446
- 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-001167 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-31: OPTIONS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (7788544188). | |
| 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 Cardiovascular Associates2026-07-31 14:23
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-189446.pdf4 pages
Itemised statement totalling $614.00 across 1 line.
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-2026-008827 | 2026-07-19 | Sunrise Dermatology Clinic | $284.00 | Approved |
| CLM-2026-023326 | 2026-07-20 | Heritage Orthopedic Specialists | $517.00 | Approved |
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.