CLM-2026-015374
Desert Heart Institute, Cardiology. Service 2026-06-05 at office (POS 11). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Nicholas Cunningham
- Member ID
- UHC-89997-78
- Date of birth
- 1971-07-18
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-432019
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6712
- Coverage period
- 2022-09-01 to 2026-02-11
- Deductible
- $361.89 of $500.0072%
- Out-of-pocket maximum
- $82.63 of $1,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 1375727520
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $315.00 | $195.30 | — | — | DeniedCO27 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $369.00 | $228.78 | — | — | DeniedCO27 |
| Totals | $684.00 | $424.08 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-652036
- 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-016306 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-05 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Desert Heart Institute (5901282678). | |
| 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 Heart Institute2026-06-05 12:35
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-26 00:53
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-05 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027998 | 2026-09-24 | Mesa Physical Therapy | $279.00 | Denied |
| CLM-2026-026226 | 2026-05-29 | Desert Primary Care Associates | $25.00 | Denied |
| CLM-2026-028834 | 2025-12-22 | Canyon Cardiovascular Associates | $455.00 | 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.