CLM-2026-016238
Unity Cardiovascular Associates, Cardiology. Service 2026-05-22 at outpatient hospital (POS 22). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Eugene Adams
- Member ID
- UHC-24119-60
- Date of birth
- 1963-11-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422905
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1031
- Coverage period
- 2023-02-01 to 2026-05-10
- Deductible
- $228.89 of $1,000.0023%
- Out-of-pocket maximum
- $647.30 of $2,000.0032%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2734278403
- Network
- In network
- Rendering NPI
- 6507319880
- Location
- Atlanta, GA · TIN 78-7453975
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,090.00 | $599.50 | — | — | DeniedCO27 |
| Totals | $1,090.00 | $599.50 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-618043
- 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-025573 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-22 is after coverage terminated on 2026-05-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 Unity Cardiovascular Associates (2734278403). | |
| 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 Associates2026-05-22 10:28
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-06 01:59
Attachments
Documents received with the claim
- Itemized billitemized_PA-618043.pdf3 pages
Itemised statement totalling $1090.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-22 is after coverage terminated on 2026-05-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028329 | 2026-03-27 | Unity Digestive Health Center | $2,366.00 | Approved |
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.