CLM-2026-016865
Northgate Cardiovascular Associates, Cardiology. Service 2025-12-13 at outpatient hospital (POS 22). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Douglas Howell
- Member ID
- UHC-59326-05
- Date of birth
- 1959-05-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416989
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8009
- Coverage period
- 2024-03-01 to present
- Deductible
- $586.57 of $1,000.0059%
- Out-of-pocket maximum
- $937.17 of $2,000.0047%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7788544188
- Network
- In network
- Rendering NPI
- 7837757195
- Location
- Denver, CO · TIN 90-6939418
- Authorisation / referral
- PHONE-503270 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,608.00 | $4,184.40 | — | — | Review |
| Totals | $7,608.00 | $4,184.40 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-197177
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-000986 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: NULL (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-503270” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| 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 Associates2025-12-13 10:27
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-04 04:33
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-197177.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-197177.pdf3 pages
Itemised statement totalling $7608.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-503270” does not match the utilisation-management format; must be confirmed before payment.
- AI recommendationPended2026-10-21 14:05The claim has a prior authorisation reference that does not match the utilisation-management format [R-prior_auth]. The provider states that the authorisation was obtained by phone [N1], but the system note indicates that the authorisation number does not match the UM system format [N2]. The prior auth letter is a handwritten reference on the provider's face sheet [A1], which does not conform to the required format. This requires confirmation before payment can be made [CO197].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 680775a2
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO197 Precertification or authorization absent
The claim has a prior authorisation reference that does not match the utilisation-management format [R-prior_auth]. The provider states that the authorisation was obtained by phone [N1], but the system note indicates that the authorisation number does not match the UM system format [N2]. The prior auth letter is a handwritten reference on the provider's face sheet [A1], which does not conform to the required format. This requires confirmation before payment can be made [CO197].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO197 Precertification or authorization absent
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.