CLM-2026-016557
Unity Cardiovascular Associates, Cardiology. Service 2026-02-07 at outpatient hospital (POS 22). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Carolyn Wright
- Member ID
- UHC-75258-31
- Date of birth
- 1981-12-24
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-426356
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2843
- Coverage period
- 2023-05-01 to present
- Deductible
- $151.69 of $500.0030%
- Out-of-pocket maximum
- $130.69 of $1,500.009%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2734278403
- Network
- In network
- Rendering NPI
- 4874619677
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $608.00 | $334.40 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $7,118.00 | $3,914.90 | — | — | DeniedCO197 |
| Totals | $7,726.00 | $4,249.30 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-187725
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-014861 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-07: CHOICE-PLUS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 14 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 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 Associates2026-02-07 15:39
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-02-21 06:48
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-187725.pdf7 pages
Itemised statement totalling $7726.00 across 2 lines.
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
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.