CLM-2026-026917
Harbor Cardiovascular Associates, Cardiology. Service 2026-04-12 at outpatient hospital (POS 22). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- John Mendez
- Member ID
- UHC-77811-84
- Date of birth
- 1971-06-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419916
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8653
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,190.07 of $3,500.0034%
- Out-of-pocket maximum
- $460.09 of $10,500.004%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1432011819
- Network
- In network
- Rendering NPI
- 5284808339
- Location
- Nashville, TN · TIN 57-5710121
- Authorisation / referral
- PA2026333956 / 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 | $5,072.00 | $2,789.60 | $2,453.83 | $335.77 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,345.00 | $739.75 | $221.93 | $517.82 | Paid |
| 3 | 93015 | Cardiovascular stress test | — | 1 | 1 | $400.00 | $220.00 | $66.00 | $154.00 | Paid |
| Totals | $6,817.00 | $3,749.35 | $2,741.76 | $1,007.59 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-707231
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004061 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-12: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026333956 on file for 93458. | |
| Provider network | Pass | In-network provider Harbor Cardiovascular Associates (1432011819). | |
| 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: Harbor Cardiovascular Associates2026-04-12 14:43
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Prior auth letterPA2026333956_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-04-12 to 2026-07-11.
- Itemized billitemized_PA-707231.pdf6 pages
Itemised statement totalling $6817.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009220 | 2026-04-05 | Canyon Cardiovascular Associates | $314.00 | Approved |
| CLM-2026-020173 | 2026-01-05 | Lakeside Imaging Center | $952.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.