CLM-2026-020563
Unity Cardiovascular Associates, Cardiology. Service 2026-02-08 at outpatient hospital (POS 22). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Joshua Griffin
- Member ID
- UHC-76115-04
- Date of birth
- 1945-12-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432044
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group NULL
- Coverage period
- 2022-03-01 to present
- Deductible
- $2,859.32 of $3,500.0082%
- Out-of-pocket maximum
- $4,102.43 of $14,000.0029%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 5466043499
- Location
- Nashville, TN · TIN 22-5957660
- Authorisation / referral
- PA2025713754 / 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 | $6,251.00 | $3,438.05 | $1,200.15 | $2,237.90 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $679.00 | $373.45 | $74.69 | $298.76 | Paid |
| Totals | $6,930.00 | $3,811.50 | $1,274.84 | $2,536.66 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-814099
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-014590 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-08: SELECT-EPO (EPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025713754 on file for 93458. | |
| Provider network | Pass | In-network provider Unity Cardiovascular Associates (6971241222). | |
| 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: Unity Cardiovascular Associates2026-02-08 11:38
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025713754_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-02-08 to 2026-05-09.
- Itemized billitemized_PA-814099.pdf7 pages
Itemised statement totalling $6930.00 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-2026-020564 | 2026-02-08 | Canyon Cardiovascular Associates | $6,930.00 | Denied |
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.