CLM-2026-027290
Northgate Cardiovascular Associates, Cardiology. Service 2026-08-18 at outpatient hospital (POS 22). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Cheryl Herrera
- Member ID
- UHC-59021-38
- Date of birth
- 1975-09-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408184
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8768
- Coverage period
- 2023-02-01 to present
- Deductible
- $418.18 of $1,500.0028%
- Out-of-pocket maximum
- $1,270.96 of $4,500.0028%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7788544188
- Network
- In network
- Rendering NPI
- 1502647435
- Location
- Denver, CO · TIN 90-6939418
- 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 | $464.00 | $255.20 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | 25 | 1 | 1 | $7,196.00 | $3,957.80 | — | — | DeniedCO197 |
| Totals | $7,660.00 | $4,213.00 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-618810
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033122 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-18: NULL (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (7788544188). | |
| 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: Northgate Cardiovascular Associates2026-08-18 17:28
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-28 00:57
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-28 17:53
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-618810.pdf3 pages
Itemised statement totalling $7660.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004425 | 2026-06-17 | Unity Counseling Center | $178.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.