CLM-2026-015453
Valley Heart Institute, Cardiology. Service 2026-03-30 at outpatient hospital (POS 22). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Sarah Morgan
- Member ID
- none on golden record
- Date of birth
- 2002-03-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401263
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-0312
- Coverage period
- 2021-11-01 to 2026-05-24
- Deductible
- $679.59 of $1,000.0068%
- Out-of-pocket maximum
- $413.64 of $2,000.0021%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 7967340598
- Location
- Atlanta, GA · TIN 70-2461607
- Authorisation / referral
- none / REF556044
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 | $1,430.00 | $786.50 | — | — | PendedIDQ |
| Totals | $1,430.00 | $786.50 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-804618
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003858; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-30: CORE-HMO (HMO), effective 2021-11-01, terms 2026-05-24. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 27 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 Valley Heart Institute (1412691184). | |
| 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: Valley Heart Institute2026-03-30 18:15
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-804618.pdf6 pages
Itemised statement totalling $1430.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003858; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-30: CORE-HMO (HMO), effective 2021-11-01, terms 2026-05-24. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.