CLM-2026-018040
Northgate Cardiovascular Associates, Cardiology. Service 2026-06-08 at outpatient hospital (POS 22). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Austin Mendoza
- Member ID
- UHC-24980-13
- Date of birth
- 1939-04-11
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-403806
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7064
- Coverage period
- 2021-06-01 to 2026-01-15
- Deductible
- $225.10 of $1,500.0015%
- Out-of-pocket maximum
- $1,170.89 of $3,000.0039%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 7586487432
- Location
- Los Angeles, CA · TIN 22-8335037
- Authorisation / referral
- PA2026285215 / REF969322
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 | $7,691.00 | $4,230.05 | — | — | DeniedCO27 |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 2 | $635.00 | $349.25 | — | — | DeniedCO27 |
| Totals | $8,326.00 | $4,579.30 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-344519
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019580 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-08 is after coverage terminated on 2026-01-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026285215 on file for 93458. | |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (5594465275). | |
| 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: Northgate Cardiovascular Associates2026-06-08 16:23
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-15 03:09
Attachments
Documents received with the claim
- Prior auth letterPA2026285215_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-06-08 to 2026-09-06.
- Itemized billitemized_PA-344519.pdf3 pages
Itemised statement totalling $8326.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-08 is after coverage terminated on 2026-01-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014217 | 2026-05-11 | Pinecrest Regional Medical Center | $1,358.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.