CLM-2026-025285
Unity Cardiovascular Associates, Cardiology. Service 2026-05-07 at outpatient hospital (POS 22). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Jean Bell
- Member ID
- UHC-44976-64
- Date of birth
- 2006-05-09
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-401526
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1278
- Coverage period
- 2021-06-01 to present
- Deductible
- $2,481.85 of $3,500.0071%
- Out-of-pocket maximum
- $2,547.00 of $7,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 6024367784
- Location
- Austin, TX · TIN 85-7157083
- 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 | $900.00 | $495.00 | — | — | Review |
| Totals | $900.00 | $495.00 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-751221
- 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-034020 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-07: MEDICARE-ADV-A (MA), effective 2021-06-01. | |
| Timely filing | Pass | Received 31 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 (3984509984). | |
| 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 essential (primary) hypertension; symptoms reviewed and ”. 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: Unity Cardiovascular Associates2026-05-07 12:31
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-07 05:10
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-07 08:52
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-751221.pdf9 pages
Itemised statement totalling $900.00 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 essential (primary) hypertension; symptoms reviewed and ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017516 | 2026-06-05 | Lakeside Medical Group | $188.00 | Approved |
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.