CLM-2026-021157
Mesa Cardiovascular Associates, Cardiology. Service 2026-08-29 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Kevin Johnston
- Member ID
- UHC-81285-76
- Date of birth
- 1956-06-01
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-432508
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4490
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,057.62 of $1,500.0071%
- Out-of-pocket maximum
- $1,959.25 of $4,500.0044%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4876629211
- Network
- In network
- Rendering NPI
- 6991428486
- Location
- Austin, TX · TIN 24-4510825
- 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 | $8,722.00 | $4,797.10 | — | — | DeniedCO197 |
| Totals | $8,722.00 | $4,797.10 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-414542
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-000942 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-29: SELECT-EPO (EPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 17 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 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Cardiovascular Associates2026-08-29 16:05
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-15 00:41
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-414542.pdf6 pages
Itemised statement totalling $8722.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009098 | 2026-04-08 | Desert Diabetes Center | $67.00 | Approved |
| CLM-2026-014090 | 2025-11-27 | Meadow Cardiovascular Associates | $773.00 | 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
Precertification required and absent.