CLM-2026-017428
Valley Heart Institute, Cardiology. Service 2026-06-09 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Angela Brown
- Member ID
- UHC-61297-62
- Date of birth
- 1946-05-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430621
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7245
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,198.39 of $2,500.0088%
- Out-of-pocket maximum
- $2,421.46 of $7,500.0032%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 6242848474
- Location
- Atlanta, GA · TIN 70-2461607
- Authorisation / referral
- PA2025428610 / 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 | $1,029.00 | $565.95 | $354.48 | $211.47 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | 25 | 1 | 1 | $5,187.00 | $2,852.85 | $570.57 | $2,282.28 | Paid |
| Totals | $6,216.00 | $3,418.80 | $925.05 | $2,493.75 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-126626
- 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-016568 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-09: MEDICARE-ADV-A (MA), effective 2022-12-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025428610 on file for 93458. | |
| Provider network | Pass | In-network provider Valley Heart Institute (1412691184). | |
| 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: Valley Heart Institute2026-06-09 16:08
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Prior auth letterPA2025428610_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-06-09 to 2026-09-07.
- Itemized billitemized_PA-126626.pdf5 pages
Itemised statement totalling $6216.00 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
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.