CLM-2026-027061
Unity Cardiovascular Associates, Cardiology. Service 2026-01-05 at outpatient hospital (POS 22). Received 2026-02-14.
Member
Resolved through the identity graph
- Member
- Lawrence Ray
- Member ID
- UHC-13779-44
- Date of birth
- 2003-02-01
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-404591
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0778
- Coverage period
- 2023-06-01 to present
- Deductible
- $399.23 of $500.0080%
- Out-of-pocket maximum
- $111.19 of $1,500.007%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 2185305705
- Location
- Austin, TX · TIN 85-7157083
- Authorisation / referral
- PA2025373226 / REF919807
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $485.00 | $266.75 | $150.56 | $116.19 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | 25 | 1 | 1,2 | $8,845.00 | $4,864.75 | $1,459.43 | $3,405.32 | Paid |
| Totals | $9,330.00 | $5,131.50 | $1,609.99 | $3,521.51 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-312844
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-007107 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-05: NAVIGATE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025373226 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 Associates2026-01-05 14:40
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025373226_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-01-05 to 2026-04-05.
- Itemized billitemized_PA-312844.pdf2 pages
Itemised statement totalling $9330.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016715 | 2026-08-03 | Northgate Imaging Center | $288.00 | Denied |
| CLM-2026-010341 | 2025-12-19 | Evergreen Clinical Laboratories | $184.00 | 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.