CLM-2026-016788
Northgate Cardiovascular Associates, Cardiology. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Mary Fields
- Member ID
- UHC-14826-97
- Date of birth
- 1941-09-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411355
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7064
- Coverage period
- 2024-04-01 to present
- Deductible
- $2,423.75 of $3,500.0069%
- Out-of-pocket maximum
- $2,222.26 of $14,000.0016%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7788544188
- Network
- In network
- Rendering NPI
- 9450471989
- Location
- Denver, CO · TIN 90-6939418
- 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 | $394.00 | $216.70 | $216.70 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,387.00 | $762.85 | $762.85 | $0.00 | Paid |
| Totals | $1,781.00 | $979.55 | $979.55 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-277829
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028403 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-09: MEDICARE-ADV-B (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 13 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 Cardiovascular Associates (7788544188). | |
| 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 Cardiovascular Associates2026-07-09 13:51
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-277829.pdf7 pages
Itemised statement totalling $1781.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025015 | 2026-04-29 | Heritage Physical Therapy | $136.00 | Denied |
| CLM-2026-025014 | 2026-04-29 | Heritage Physical Therapy | $136.00 | Approved |
| CLM-2026-006886 | 2026-04-07 | Riverside Bone and Joint Center | $8,470.00 | 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.