CLM-2026-015932
Valley Heart Institute, Cardiology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Juan Harris
- Member ID
- UHC-78189-72
- Date of birth
- 1965-11-17
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-412327
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group NULL
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,446.25 of $3,500.0041%
- Out-of-pocket maximum
- $112.88 of $10,500.001%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 8170395593
- Location
- Atlanta, GA · TIN 70-2461607
- Authorisation / referral
- none / REF485413
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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,938.00 | $3,815.90 | — | — | DeniedCO197 |
| Totals | $6,938.00 | $3,815.90 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-766276
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005106 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-07: NAVIGATE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 10 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 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 Institute2026-01-07 14:14
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-17 00:46
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-766276.pdf4 pages
Itemised statement totalling $6938.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023028 | 2026-03-25 | Unity Digestive Health Center | $305.00 | Approved |
| CLM-2026-007057 | 2025-12-11 | Evergreen Rehabilitation Center | $7,832.00 | Needs review |
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.