CLM-2026-026071
Northgate Heart Institute, Cardiology. Service 2025-11-27 at office (POS 11). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Charles Lane
- Member ID
- UHC-26831-50
- Date of birth
- 1953-12-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-404989
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0395
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,814.46 of $3,500.0052%
- Out-of-pocket maximum
- $5,087.37 of $10,500.0048%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 4890778606
- Location
- San Diego, CA · TIN 46-7688844
- Authorisation / referral
- none / REF851762
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $468.00 | $290.16 | — | — | DeniedCO29 |
| Totals | $468.00 | $290.16 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-848896
- 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-014477 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-27: NAVIGATE-HMO (HMO), effective 2023-07-01. | |
| Timely filing | Fail | CO29 | Received 115 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (5192135197). | |
| 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 Institute2025-11-27 18:54
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-22 01:03
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-22 14:29
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 115 days after the last date of service (limit 90).
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
Received after the timely-filing limit.