CLM-2026-026926
Desert Cardiovascular Associates, Cardiology. Service 2026-05-09 at outpatient hospital (POS 22). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Paul Murphy
- Member ID
- UHC-27643-08
- Date of birth
- 1957-04-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-423331
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8350
- Coverage period
- 2022-01-01 to present
- Deductible
- $121.13 of $1,500.008%
- Out-of-pocket maximum
- $188.44 of $3,000.006%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 5166750344
- Location
- Houston, TX · TIN 63-6537518
- Authorisation / referral
- PA2026420541 / REF893458
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 | $7,310.00 | $4,020.50 | $1,643.03 | $2,377.47 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1,2 | $1,399.00 | $769.45 | $76.95 | $692.50 | Paid |
| Totals | $8,709.00 | $4,789.95 | $1,719.98 | $3,069.97 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-917536
- 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-031003 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-09: NAVIGATE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026420541 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (1421288352). | |
| 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: Desert Cardiovascular Associates2026-05-09 10:05
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Prior auth letterPA2026420541_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-09 to 2026-08-07.
- Itemized billitemized_PA-917536.pdf5 pages
Itemised statement totalling $8709.00 across 2 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
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.