CLM-2026-017074
Evergreen Cardiovascular Associates, Cardiology. Service 2026-06-19 at outpatient hospital (POS 22). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Martha Turner
- Member ID
- UHC-64123-35
- Date of birth
- 1962-05-24
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-403565
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4876
- Coverage period
- 2023-10-01 to present
- Deductible
- $478.20 of $1,000.0048%
- Out-of-pocket maximum
- $1,389.21 of $3,000.0046%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5300844821
- Network
- In network
- Rendering NPI
- 2601220819
- Location
- Tempe, AZ · TIN 12-5704558
- Authorisation / referral
- PA2025339006 / 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $906.00 | $498.30 | $498.30 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,429.00 | $4,635.95 | $1,407.24 | $3,228.71 | Paid |
| Totals | $9,335.00 | $5,134.25 | $1,905.54 | $3,228.71 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-847076
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034783 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-19: MEDICARE-ADV-A (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025339006 on file for 93458. | |
| Provider network | Pass | In-network provider Evergreen Cardiovascular Associates (5300844821). | |
| 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: Evergreen Cardiovascular Associates2026-06-19 14:17
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Prior auth letterPA2025339006_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-06-19 to 2026-09-17.
- Itemized billitemized_PA-847076.pdf8 pages
Itemised statement totalling $9335.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022155 | 2026-06-11 | Unity Primary Care Associates | $295.00 | 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.