CLM-2026-025580
Desert Cardiovascular Associates, Cardiology. Service 2026-07-06 at outpatient hospital (POS 22). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Carolyn Lewis
- Member ID
- UHC-83255-14
- Date of birth
- 1996-08-27
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-400931
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4111
- Coverage period
- 2022-10-01 to 2026-01-12
- Deductible
- $2,768.40 of $3,500.0079%
- Out-of-pocket maximum
- $3,349.09 of $7,000.0048%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 8725689128
- Location
- Houston, TX · TIN 63-6537518
- Authorisation / referral
- PA2026310759 / 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 | $5,536.00 | $3,044.80 | — | — | DeniedCO27 |
| Totals | $5,536.00 | $3,044.80 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-371649
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002645 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-06 is after coverage terminated on 2026-01-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026310759 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (1421288352). | |
| 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: Desert Cardiovascular Associates2026-07-06 11:55
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-16 02:45
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-16 10:58
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026310759_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-07-06 to 2026-10-04.
- Itemized billitemized_PA-371649.pdf6 pages
Itemised statement totalling $5536.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-06 is after coverage terminated on 2026-01-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021396 | 2025-12-18 | Lakeside Skin Care Associates | $666.00 | Approved |
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
Service after coverage termination.