CLM-2026-028184
Pinecrest Heart Institute, Cardiology. Service 2026-02-21 at outpatient hospital (POS 22). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Ronald Padilla
- Member ID
- UHC-04677-70
- Date of birth
- 2001-08-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-413359
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9885
- Coverage period
- 2025-09-01 to present
- Deductible
- $735.20 of $1,500.0049%
- Out-of-pocket maximum
- $16.67 of $6,000.000%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 8059538594
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- PA2025596571 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,589.00 | $3,623.95 | $1,336.63 | $2,287.32 | Paid |
| Totals | $6,589.00 | $3,623.95 | $1,336.63 | $2,287.32 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-775877
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-021175 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-21: SELECT-EPO (EPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025596571 on file for 93458. | |
| Provider network | Pass | In-network provider Pinecrest Heart Institute (8218526324). | |
| 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: Pinecrest Heart Institute2026-02-21 13:51
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025596571_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-02-21 to 2026-05-22.
- Itemized billitemized_PA-775877.pdf4 pages
Itemised statement totalling $6589.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017727 | 2026-08-21 | Riverside Medical Group | $303.00 | Approved |
| CLM-2026-026504 | 2026-07-29 | Heritage Primary Care Associates | $13.00 | Approved |
| CLM-2026-028185 | 2026-02-21 | Pinecrest Heart Institute | $6,589.00 | Needs review |
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.