CLM-2026-016882
Riverside Cardiovascular Associates, Cardiology. Service 2026-05-08 at outpatient hospital (POS 22). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Wei Harrison
- Member ID
- UHC-67650-36
- Date of birth
- 1954-03-02
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-404895
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7823
- Coverage period
- 2022-05-01 to present
- Deductible
- $623.43 of $1,000.0062%
- Out-of-pocket maximum
- $286.54 of $3,000.0010%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 8613506780
- Location
- Atlanta, GA · TIN 37-2658699
- 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 | $453.00 | $249.15 | $249.15 | $0.00 | Paid |
| Totals | $453.00 | $249.15 | $249.15 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-334609
- 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-014493 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-08: N/A (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 6 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 Riverside Cardiovascular Associates (4236552608). | |
| 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: Riverside Cardiovascular Associates2026-05-08 18:35
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-334609.pdf6 pages
Itemised statement totalling $453.00 across 1 line.
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-2026-008439 | 2026-07-02 | Pinecrest Bone and Joint Center | $8,359.00 | Denied |
| CLM-2026-000468 | 2026-01-07 | Valley Skin Care Associates | $472.00 | 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.