CLM-2026-028567
Northgate Cardiovascular Associates, Cardiology. Service 2026-03-16 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Susan Bell
- Member ID
- UHC-59959-19
- Date of birth
- 1980-04-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-402488
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5979
- Coverage period
- 2021-08-01 to present
- Deductible
- $759.65 of $3,500.0022%
- Out-of-pocket maximum
- $2,883.45 of $10,500.0027%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 3742666761
- Location
- Los Angeles, CA · TIN 22-8335037
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $386.00 | $239.32 | $75.00 | $164.32 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $229.00 | $141.98 | $0.00 | $141.98 | Paid |
| Totals | $615.00 | $381.30 | $75.00 | $306.30 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-307583
- 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-026138 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-16: MEDICARE-ADV-B (MA), effective 2021-08-01. | |
| Timely filing | Pass | Received 31 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 Associates2026-03-16 11:42
Patient seen for heart failure, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-04-16 03:02
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-16 17:34
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-307583.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
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
Authorisation must be confirmed with UM before payment.