CLM-2026-024993
Northgate Heart Institute, Cardiology. Service 2026-08-28 at outpatient hospital (POS 22). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Noah Dixon
- Member ID
- UHC-37800-54
- Date of birth
- 1968-05-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424542
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3145
- Coverage period
- 2025-07-01 to present
- Deductible
- $314.47 of $500.0063%
- Out-of-pocket maximum
- $449.15 of $1,500.0030%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 1736147111
- Location
- Los Angeles, CA · TIN 48-8536899
- Authorisation / referral
- PA2025889719 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $9,040.00 | $4,972.00 | $664.18 | $4,307.82 | Paid |
| Totals | $9,040.00 | $4,972.00 | $664.18 | $4,307.82 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-405202
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-004885 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-28: SELECT-EPO (EPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025889719 on file for 93458. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (1929886434). | |
| 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: Northgate Heart Institute2026-08-28 14:23
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025889719_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-28 to 2026-11-26.
- Itemized billitemized_PA-405202.pdf9 pages
Itemised statement totalling $9040.00 across 1 line.
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-2026-024994 | 2026-08-28 | Northgate Heart Institute | $9,040.00 | Needs review |
| CLM-2026-026870 | 2026-03-12 | Northgate Clinical Laboratories | $73.00 | 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.