CLM-2026-022121
Summit Heart Institute, Cardiology. Service 2026-07-11 at outpatient hospital (POS 22). Received 2026-07-27.
Member
Resolved through the identity graph
- Member
- Zachary Maldonado
- Member ID
- UHC-14103-56
- Date of birth
- 1987-02-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418073
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3560
- Coverage period
- 2022-05-01 to present
- Deductible
- $503.10 of $3,500.0014%
- Out-of-pocket maximum
- $548.03 of $7,000.008%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 1129754663
- Location
- Tampa, FL · TIN 24-2775289
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,202.00 | $661.10 | $661.10 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 1 | $503.00 | $276.65 | $276.65 | $0.00 | Paid |
| Totals | $1,705.00 | $937.75 | $937.75 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-526160
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002270 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-11: CHOICE-PLUS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Heart Institute (1318552993). | |
| 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: Summit Heart Institute2026-07-11 15:43
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-526160.pdf5 pages
Itemised statement totalling $1705.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022118 | 2026-04-14 | Unity Physical Therapy | $306.00 | Approved |
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.