CLM-2026-021653
Unity Cardiovascular Associates, Cardiology. Service 2026-01-26 at outpatient hospital (POS 22). Received 2026-02-26.
Member
Resolved through the identity graph
- Member
- Judith Peters
- Member ID
- none on golden record
- Date of birth
- 1972-01-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-408102
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2734278403
- Network
- In network
- Rendering NPI
- 5192184310
- Location
- Atlanta, GA · TIN 78-7453975
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $468.00 | $257.40 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $9,283.00 | $5,105.65 | — | — | DeniedCO197 |
| Totals | $9,751.00 | $5,363.05 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-944271
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015921 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 31 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 Unity Cardiovascular Associates (2734278403). | |
| 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 Associates2026-01-26 13:04
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-26 03:07
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-944271.pdf6 pages
Itemised statement totalling $9751.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028811 | 2026-05-07 | Canyon Regional Medical Center | $1,226.00 | Pended |
| CLM-2026-023891 | 2026-04-18 | Mesa Clinical Laboratories | $131.00 | Pended |
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.