CLM-2026-017721
Evergreen Cardiovascular Associates, Cardiology. Service 2026-09-01 at outpatient hospital (POS 22). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Donald Daniels
- Member ID
- UHC-99841-01
- Date of birth
- 2001-05-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421066
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2925
- Coverage period
- 2024-02-01 to present
- Deductible
- $144.87 of $1,000.0014%
- Out-of-pocket maximum
- $213.00 of $4,000.005%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5300844821
- Network
- In network
- Rendering NPI
- 1067841472
- Location
- Tempe, AZ · TIN 12-5704558
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,599.00 | $879.45 | $859.99 | $19.46 | Paid |
| Totals | $1,599.00 | $879.45 | $859.99 | $19.46 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-252538
- 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-013465 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-01: OPTIONS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 25 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 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 Associates2026-09-01 13:27
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-252538.pdf8 pages
Itemised statement totalling $1599.00 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
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.