CLM-2026-024513
Summit Heart Institute, Cardiology. Service 2026-08-29 at outpatient hospital (POS 22). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Nancy Harvey
- Member ID
- UHC-47422-60
- Date of birth
- 1994-03-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428599
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2547
- Coverage period
- 2021-07-01 to present
- Deductible
- $2,006.92 of $2,500.0080%
- Out-of-pocket maximum
- $602.05 of $5,000.0012%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 7155104103
- 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 | $1,422.00 | $782.10 | — | — | DeniedCO197 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $407.00 | $223.85 | — | — | DeniedCO197 |
| 3 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $6,661.00 | $3,663.55 | — | — | DeniedCO197 |
| Totals | $8,490.00 | $4,669.50 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-820341
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037748 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-29: CHOICE-PLUS-PPO (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 35 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 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 Institute2026-08-29 13:56
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-03 02:16
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-820341.pdf3 pages
Itemised statement totalling $8490.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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.