CLM-2026-021270
Harbor Cardiovascular Associates, Cardiology. Service 2026-05-14 at office (POS 11). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Julie Stone
- Member ID
- UHC-40739-50
- Date of birth
- 1998-01-11
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-410792
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9109
- Coverage period
- 2021-10-01 to present
- Deductible
- $181.77 of $500.0036%
- Out-of-pocket maximum
- $291.82 of $1,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1432011819
- Network
- In network
- Rendering NPI
- 1192669269
- Location
- Nashville, TN · TIN 57-5710121
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $393.00 | $243.66 | — | — | DeniedCO18 |
| Totals | $393.00 | $243.66 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-332753
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-026216 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-05-14: OPTIONS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021269: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Cardiovascular Associates (1432011819). | |
| 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: Harbor Cardiovascular Associates2026-05-14 14:35
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-26 05:57
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-26 12:38
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-021269: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021269 | 2026-05-14 | Harbor Cardiovascular Associates | $393.00 | 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
Exact duplicate of an earlier submission.