CLM-2026-015170
Unity Cardiovascular Associates, Cardiology. Service 2026-01-13 at outpatient hospital (POS 22). Received 2026-01-30.
Member
Resolved through the identity graph
- Member
- Barbara James
- Member ID
- UHC-77875-98
- Date of birth
- 1988-06-23
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418433
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9657
- Coverage period
- 2024-02-01 to present
- Deductible
- $300.15 of $500.0060%
- Out-of-pocket maximum
- $742.59 of $2,000.0037%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 3937101731
- Location
- Nashville, TN · TIN 22-5957660
- 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 | $429.00 | $235.95 | — | — | DeniedCO197 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,169.00 | $642.95 | — | — | DeniedCO197 |
| 3 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $5,875.00 | $3,231.25 | — | — | DeniedCO197 |
| Totals | $7,473.00 | $4,110.15 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-609017
- 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-008862 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-13: UNKNOWN (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 17 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 Unity Cardiovascular Associates (6971241222). | |
| 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: Unity Cardiovascular Associates2026-01-13 10:43
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-30 01:25
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-609017.pdf5 pages
Itemised statement totalling $7473.00 across 3 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.