CLM-2026-027813
Valley Heart Institute, Cardiology. Service 2026-04-12 at outpatient hospital (POS 22). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Carol Ruiz
- Member ID
- UHC-33407-76
- Date of birth
- 2007-05-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-429867
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9085
- Coverage period
- 2025-06-01 to present
- Deductible
- $417.04 of $1,500.0028%
- Out-of-pocket maximum
- $2,319.94 of $6,000.0039%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 7271077928
- Location
- Atlanta, GA · TIN 70-2461607
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,397.00 | $768.35 | $768.35 | $0.00 | Paid |
| Totals | $1,397.00 | $768.35 | $768.35 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-229505
- 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-023943 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-12: MEDICARE-ADV-A (MA), effective 2025-06-01. | |
| Timely filing | Pass | Received 24 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 Valley Heart Institute (1412691184). | |
| 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: Valley Heart Institute2026-04-12 17:05
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-229505.pdf9 pages
Itemised statement totalling $1397.00 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-2026-031871 | 2026-09-22 | Pinecrest Physical Therapy | $80.00 | Needs review |
| CLM-2026-031870 | 2026-09-22 | Pinecrest Physical Therapy | $320.00 | 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.