CLM-2026-017381
Desert Heart Institute, Cardiology. Service 2025-12-27 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Judith Ramirez
- Member ID
- UHC-46061-12
- Date of birth
- 1983-10-07
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-424474
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1503
- Coverage period
- 2022-03-01 to present
- Deductible
- $617.73 of $1,500.0041%
- Out-of-pocket maximum
- $153.62 of $4,500.003%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 2007801329
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- PA2025650497 / 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 | $1,281.00 | $704.55 | $704.55 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,353.00 | $2,944.15 | $1,007.65 | $1,936.50 | Paid |
| Totals | $6,634.00 | $3,648.70 | $1,712.20 | $1,936.50 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-208978
- 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-001658 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-27: MEDICARE-ADV-A (MA), effective 2022-03-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025650497 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Heart Institute (5901282678). | |
| 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 Heart Institute2025-12-27 16:27
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025650497_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2025-12-27 to 2026-03-27.
- Itemized billitemized_PA-208978.pdf6 pages
Itemised statement totalling $6634.00 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-2026-002116 | 2026-07-17 | Valley Family Practice | $255.00 | 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.