CLM-2026-016587
Unity Cardiovascular Associates, Cardiology. Service 2026-09-02 at office (POS 11). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Henry King
- Member ID
- UHC-09665-72
- Date of birth
- 1953-06-24
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-432032
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8141
- Coverage period
- 2021-09-01 to 2026-06-10
- Deductible
- $547.35 of $3,500.0016%
- Out-of-pocket maximum
- $2,847.23 of $7,000.0041%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 7999508451
- Location
- Nashville, TN · TIN 22-5957660
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $382.00 | $236.84 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1,2 | $318.00 | $197.16 | — | — | DeniedCO27 |
| Totals | $700.00 | $434.00 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-478901
- 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-018726 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-02 is after coverage terminated on 2026-06-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 (6971241222). | |
| 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 Associates2026-09-02 09:22
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-05 03:37
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-05 08:34
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-02 is after coverage terminated on 2026-06-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008786 | 2026-03-06 | Desert Medical Group | $55.00 | 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.