CLM-2026-024104
Unity Cardiovascular Associates, Cardiology. Service 2026-06-20 at outpatient hospital (POS 22). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Alan Bradley
- Member ID
- UHC-52468-29
- Date of birth
- 1975-10-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417798
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group UNKNOWN
- Coverage period
- 2024-08-01 to present
- Deductible
- $34.92 of $1,500.002%
- Out-of-pocket maximum
- $912.38 of $3,000.0030%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2734278403
- Network
- In network
- Rendering NPI
- 5614953524
- 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 | $475.00 | $261.25 | — | — | PendedIDQ |
| 2 | 93306 rev 0480 | Echocardiogram, complete | 25 | 1 | 1 | $1,348.00 | $741.40 | — | — | PendedIDQ |
| Totals | $1,823.00 | $1,002.65 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-403965
- 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 | Fail | IDQ | Member record is in open steward case CASE-000536; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-20: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 4 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 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 Associates2026-06-20 09:24
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-403965.pdf9 pages
Itemised statement totalling $1823.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000536; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.