CLM-2026-022327
Desert Cardiovascular Associates, Cardiology. Service 2026-04-25 at outpatient hospital (POS 22). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Christian Hudson
- Member ID
- UHC-86325-72
- Date of birth
- 1969-07-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400916
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7983
- Coverage period
- 2024-08-01 to present
- Deductible
- $350.23 of $500.0070%
- Out-of-pocket maximum
- $282.35 of $1,000.0028%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 2497023236
- Location
- Houston, TX · TIN 63-6537518
- Authorisation / referral
- PA2025680595 / 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 | $396.00 | $217.80 | $163.38 | $54.42 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,575.00 | $4,166.25 | $833.25 | $3,333.00 | Paid |
| 3 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,333.00 | $733.15 | $146.63 | $586.52 | Paid |
| Totals | $9,304.00 | $5,117.20 | $1,143.26 | $3,973.94 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-469331
- 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-002429 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-25: MEDICARE-ADV-B (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025680595 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (1421288352). | |
| 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: Desert Cardiovascular Associates2026-04-25 15:52
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025680595_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-04-25 to 2026-07-24.
- Itemized billitemized_PA-469331.pdf9 pages
Itemised statement totalling $9304.00 across 3 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
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.