CLM-2026-026916
Unity Cardiovascular Associates, Cardiology. Service 2025-12-18 at outpatient hospital (POS 22). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Elijah Aguilar
- Member ID
- none on golden record
- Date of birth
- 1996-12-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407443
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-3304
- Coverage period
- 2021-01-01 to 2026-03-19
- Deductible
- $29.68 of $500.006%
- Out-of-pocket maximum
- $176.20 of $1,000.0018%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 4315450740
- Location
- Austin, TX · TIN 85-7157083
- Authorisation / referral
- PA2025268191 / REF934719
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 | $5,381.00 | $2,959.55 | — | — | PendedIDQ |
| Totals | $5,381.00 | $2,959.55 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-538879
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001413; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-18: NAVIGATE-HMO (HMO), effective 2021-01-01, terms 2026-03-19. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025268191 on file for 93458. | |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Cardiovascular Associates2025-12-18 11:26
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025268191_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2025-12-18 to 2026-03-18.
- Itemized billitemized_PA-538879.pdf4 pages
Itemised statement totalling $5381.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001413; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-18: NAVIGATE-HMO (HMO), effective 2021-01-01, terms 2026-03-19. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.