CLM-2026-019122
Cornerstone Cardiovascular Associates, Cardiology. Service 2026-05-23 at outpatient hospital (POS 22). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Mei Miller
- Member ID
- UHC-86504-87
- Date of birth
- 1981-04-16
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-429253
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2049
- Coverage period
- 2024-05-01 to present
- Deductible
- $74.13 of $500.0015%
- Out-of-pocket maximum
- $725.36 of $2,000.0036%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2414323685
- Network
- In network
- Rendering NPI
- 5286824763
- Location
- Nashville, TN · TIN 96-9778559
- Authorisation / referral
- PA2026924548 / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $531.00 | $292.05 | $292.05 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,394.00 | $3,516.70 | $810.40 | $2,706.30 | Paid |
| Totals | $6,925.00 | $3,808.75 | $1,102.45 | $2,706.30 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-965310
- 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-012661 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-23: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026924548 on file for 93458. | |
| Provider network | Pass | In-network provider Cornerstone Cardiovascular Associates (2414323685). | |
| 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: Cornerstone Cardiovascular Associates2026-05-23 10:33
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026924548_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-05-23 to 2026-08-21.
- Itemized billitemized_PA-965310.pdf7 pages
Itemised statement totalling $6925.00 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-2026-024205 | 2026-07-02 | Heritage Clinical Laboratories | $102.00 | Needs review |
| CLM-2026-024204 | 2026-07-02 | Heritage Clinical Laboratories | $102.00 | Approved |
| CLM-2026-026389 | 2026-02-09 | Desert Primary Care Associates | $40.00 | 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.