Claims workbench/CLM-2026-026126

Institutional claim · UB-04 · EDI 837I

CLM-2026-026126

Pinecrest Cardiovascular Associates, Cardiology. Service 2025-11-28 at outpatient hospital (POS 22). Received 2026-01-10.

Denied

Billed

$9,501.00

2 lines

Allowed

$5,225.55

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Brian Cox
Member ID: UHC-39816-02
Date of birth: 1980-04-19
Identity: Verified6 records, confidence 0.96
Claim record: CLMCLM-401428
Relationship: Self, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-3965
Coverage period: 2025-12-01 to present
Deductible: $395.43 of $3,500.0011%
Out-of-pocket maximum: $1,507.53 of $7,000.0022%
Copays: office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 4926340728
Network: In network
Rendering NPI: 2151469576
Location: Houston, TX · TIN 79-8590773
Authorisation / referral: PA2026039864 / REF191617

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	$8,807.00	$4,843.85	—	—	DeniedN30
2	93015	Cardiovascular stress test	—	1	1	$694.00	$381.70	—	—	DeniedN30
Totals						$9,501.00	$5,225.55	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal
2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
3. I10 Essential (primary) hypertension

Claim header

Patient account: PA-205641
Frequency code: 1 (original)
Accident: No
DRG: 287
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-003196 (verified, link confidence 0.96).
Eligibility	Fail	N30	Date of service 2025-11-28 is before coverage effective date 2025-12-01. Patient ineligible for this service
Timely filing	Pass		Received 43 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026039864 on file for 93458.
Provider network	Pass		In-network provider Pinecrest Cardiovascular Associates (4926340728).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Cardiovascular Associates2025-11-28 16:15
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Prior auth letterPA2026039864_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2025-11-28 to 2026-02-26.
Itemized billitemized_PA-205641.pdf2 pages
Itemised statement totalling $9501.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2025-11-28 is before coverage effective date 2025-12-01.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-026281	2026-04-26	Lakeside Physical Therapy	$451.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity