CLM-2026-017298
Desert Cardiovascular Associates, Cardiology. Service 2026-06-01 at outpatient hospital (POS 22). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Matthew Castro
- Member ID
- UHC-06484-78
- Date of birth
- 1999-02-28
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-406928
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2023-10-01 to present
- Deductible
- $236.22 of $1,000.0024%
- Out-of-pocket maximum
- $1,202.59 of $3,000.0040%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 9616741663
- Location
- Houston, TX · TIN 63-6537518
- Authorisation / referral
- PA2025139781 / 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 | $8,504.00 | $4,677.20 | $1,155.12 | $3,522.08 | Paid |
| Totals | $8,504.00 | $4,677.20 | $1,155.12 | $3,522.08 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-744715
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-023160 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-01: MEDICARE-ADV-B (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025139781 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (1421288352). | |
| 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: Desert Cardiovascular Associates2026-06-01 16:47
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025139781_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-06-01 to 2026-08-30.
- Itemized billitemized_PA-744715.pdf9 pages
Itemised statement totalling $8504.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003236 | 2026-05-03 | Evergreen Dermatology Clinic | $502.00 | 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.