CLM-2026-028173
Northgate Cardiovascular Associates, Cardiology. Service 2026-05-10 at outpatient hospital (POS 22). Received 2026-06-19.
Member
Resolved through the identity graph
- Member
- Jacob Riley
- Member ID
- UHC-23169-11
- Date of birth
- 1943-04-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-425100
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8544
- Coverage period
- 2022-08-01 to present
- Deductible
- $323.50 of $500.0065%
- Out-of-pocket maximum
- $422.19 of $1,500.0028%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 8183977726
- Location
- Los Angeles, CA · TIN 22-8335037
- 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 | $1,414.00 | $777.70 | $356.86 | $420.84 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $649.00 | $356.95 | $107.09 | $249.86 | Paid |
| Totals | $2,063.00 | $1,134.65 | $463.95 | $670.70 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-281651
- 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-010027 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-10: - (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (5594465275). | |
| 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 Associates2026-05-10 09:28
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-281651.pdf8 pages
Itemised statement totalling $2063.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014393 | 2026-08-24 | Pinecrest Primary Care Associates | $207.00 | Approved |
| CLM-2026-006209 | 2026-01-20 | Unity Internal Medicine Associates | $86.00 | 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.