CLM-2026-019467
Lakeside Heart Institute, Cardiology. Service 2026-09-04 at office (POS 11). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Diego Bishop
- Member ID
- UHC-89423-86
- Date of birth
- 1959-12-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-401182
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7143
- Coverage period
- 2022-05-01 to 2026-08-15
- Deductible
- $567.08 of $1,500.0038%
- Out-of-pocket maximum
- $1,676.32 of $4,500.0037%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8827628438
- Network
- In network
- Rendering NPI
- 9174356201
- Location
- Houston, TX · TIN 99-8948998
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $272.00 | $168.64 | — | — | DeniedCO27 |
| Totals | $272.00 | $168.64 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-947247
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-022430 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-04 is after coverage terminated on 2026-08-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 Lakeside Heart Institute (8827628438). | |
| 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: Lakeside Heart Institute2026-09-04 16:58
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-14 05:22
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-14 13:25
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-04 is after coverage terminated on 2026-08-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029772 | 2026-07-20 | Canyon Medical Group | $212.00 | Approved |
| CLM-2026-029619 | 2026-07-20 | Northgate Heart Institute | $775.00 | Needs review |
| CLM-2026-017342 | 2026-03-08 | Riverside Medical Group | $727.00 | Approved |
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.