CLM-2026-027219
Desert Cardiovascular Associates, Cardiology. Service 2026-09-19 at outpatient hospital (POS 22). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Amber Walker
- Member ID
- UHC-76429-95
- Date of birth
- 1993-08-19
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-400944
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9282
- Coverage period
- 2025-07-01 to present
- Deductible
- $197.50 of $1,500.0013%
- Out-of-pocket maximum
- $1,344.49 of $3,000.0045%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5097822972
- Network
- In network
- Rendering NPI
- 5059019609
- Location
- Mesa, AZ · TIN 54-0867004
- Authorisation / referral
- none / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $596.00 | $327.80 | $327.80 | $0.00 | Paid |
| Totals | $596.00 | $327.80 | $327.80 | $0.00 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-938833
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038473 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-19: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (5097822972). | |
| 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 Associates2026-09-19 15:15
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-938833.pdf7 pages
Itemised statement totalling $596.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027220 | 2026-09-19 | Desert Cardiovascular Associates | $596.00 | Needs review |
| CLM-2026-022715 | 2026-07-16 | Lakeside Internal Medicine Associates | $331.00 | Approved |
| CLM-2026-005992 | 2026-07-05 | Unity Physical Therapy | $288.00 | 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.