CLM-2026-020265
Cornerstone Cardiovascular Associates, Cardiology. Service 2026-04-30 at outpatient hospital (POS 22). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Dorothy Phillips
- Member ID
- UHC-59853-62
- Date of birth
- 1950-04-04
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412437
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9797
- Coverage period
- 2023-08-01 to present
- Deductible
- $191.42 of $1,000.0019%
- Out-of-pocket maximum
- $323.48 of $4,000.008%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2414323685
- Network
- In network
- Rendering NPI
- 5952787310
- Location
- Nashville, TN · TIN 96-9778559
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,409.00 | $4,624.95 | — | — | DeniedCO197 |
| Totals | $8,409.00 | $4,624.95 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-565104
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030725 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-30: CHOICE-PLUS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Associates2026-04-30 16:05
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-15 01:47
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-15 16:27
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-565104.pdf9 pages
Itemised statement totalling $8409.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.