Claims workbench/CLM-2026-026244

Institutional claim · UB-04 · Provider portal

CLM-2026-026244

Desert Heart Institute, Cardiology. Service 2026-03-11 at outpatient hospital (POS 22). Received 2026-09-20.

Denied

Billed

$5,581.00

1 line

Allowed

$3,069.55

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jackie Diaz
Member ID: UHC-15009-91
Date of birth: 1955-12-28
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-423239
Relationship: Child, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-2984
Coverage period: 2024-10-01 to present
Deductible: $419.75 of $500.0084%
Out-of-pocket maximum: $279.29 of $1,500.0019%
Copays: office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Desert Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 5901282678
Network: In network
Rendering NPI: 4842152587
Location: Mesa, AZ · TIN 39-5178200
Authorisation / referral: PA2025075997 / 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	$5,581.00	$3,069.55	—	—	DeniedCO29
Totals						$5,581.00	$3,069.55	—	—

Diagnoses (ICD-10-CM)

1. I50.9 Heart failure, unspecifiedprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-254015
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-022650 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-03-11: MEDICARE-ADV-B (MA), effective 2024-10-01.
Timely filing	Fail	CO29	Received 193 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		Authorisation PA2025075997 on file for 93458.
Provider network	Pass		In-network provider Desert Heart Institute (5901282678).
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: Desert Heart Institute2026-03-11 16:42
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-09-20 05:31
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-20 09:07
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025075997_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-03-11 to 2026-06-09.
Itemized billitemized_PA-254015.pdf5 pages
Itemised statement totalling $5581.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 193 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-003606	2026-09-09	Sunrise Dermatology Clinic	$393.00	Approved
CLM-2026-016157	2026-05-22	Northgate Medical Group	$444.00	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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity