CLM-2026-015620
Northgate Heart Institute, Cardiology. Service 2026-08-22 at outpatient hospital (POS 22). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Laura Powell
- Member ID
- UHC-45064-52
- Date of birth
- 1969-05-21
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-410846
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group N/A
- Coverage period
- 2021-01-01 to present
- Deductible
- $276.14 of $1,500.0018%
- Out-of-pocket maximum
- $844.06 of $3,000.0028%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 4208762557
- Location
- Los Angeles, CA · TIN 48-8536899
- 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 | $441.00 | $242.55 | $242.55 | $0.00 | Paid |
| Totals | $441.00 | $242.55 | $242.55 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-391756
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-017116 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-22: CHOICE-PLUS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 4 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 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 Institute2026-08-22 11:52
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-391756.pdf7 pages
Itemised statement totalling $441.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013099 | 2026-04-02 | Heritage Primary Care Associates | $711.00 | 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.