Claims workbench/CLM-2026-020303

Institutional claim · UB-04 · Provider portal

CLM-2026-020303

Mesa Cardiovascular Associates, Cardiology. Service 2025-09-09 at outpatient hospital (POS 22). Received 2026-01-03.

DeniedIdentity on hold: CASE-000318

Billed

$7,846.00

2 lines

Allowed

$4,315.30

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: James Wilson
Member ID: none on golden record
Date of birth: 1998-04-08
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-420063
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-5868
Coverage period: 2025-07-01 to present
Deductible: $924.03 of $1,500.0062%
Out-of-pocket maximum: $1,466.48 of $3,000.0049%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Mesa Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 4876629211
Network: In network
Rendering NPI: 9562915162
Location: Austin, TX · TIN 24-4510825
Authorisation / referral: PA2026880524 / REF251410

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	$379.00	$208.45	—	—	DeniedCO29
2	93458 rev 0481	Cardiac catheterisation, left heart	—	1	2	$7,467.00	$4,106.85	—	—	DeniedCO29
Totals						$7,846.00	$4,315.30	—	—

Diagnoses (ICD-10-CM)

1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-744820
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-000318; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2025-09-09: NAVIGATE-HMO (HMO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Fail	CO29	Received 116 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026880524 on file for 93458.
Provider network	Pass		In-network provider Mesa Cardiovascular Associates (4876629211).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Mesa Cardiovascular Associates2025-09-09 18:43
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-01-03 02:35
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-03 17:30
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026880524_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2025-09-09 to 2025-12-08.
Itemized billitemized_PA-744820.pdf2 pages
Itemised statement totalling $7846.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000318; payment withheld until the identity is confirmed. Eligibility: Active on 2025-09-09: NAVIGATE-HMO (HMO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 116 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity