CLM-2026-024716
Valley Cardiovascular Associates, Cardiology. Service 2026-03-08 at outpatient hospital (POS 22). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Zachary Thompson
- Member ID
- UHC-15871-31
- Date of birth
- 1973-11-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405710
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7198
- Coverage period
- 2023-10-01 to present
- Deductible
- $183.14 of $500.0037%
- Out-of-pocket maximum
- $373.67 of $2,000.0019%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4553481845
- Network
- In network
- Rendering NPI
- 1404144903
- Location
- Dallas, TX · TIN 18-8856969
- 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 | $429.00 | $235.95 | — | — | Review |
| Totals | $429.00 | $235.95 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-624052
- 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-024289 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-08: NULL (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 29 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 Valley Cardiovascular Associates (4553481845). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with atherosclerotic heart disease of native coronary artery ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Cardiovascular Associates2026-03-08 14:19
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-06 04:04
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-06 13:21
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-624052.pdf7 pages
Itemised statement totalling $429.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with atherosclerotic heart disease of native coronary artery ”.
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
Development letter outstanding.