CLM-2026-029410
Valley Heart Institute, Cardiology. Service 2025-09-22 at office (POS 11). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Russll Gardner
- Member ID
- UHC-36460-47
- Date of birth
- 1988-02-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414760
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3587
- Coverage period
- 2021-07-01 to present
- Deductible
- $308.83 of $500.0062%
- Out-of-pocket maximum
- $295.99 of $1,500.0020%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 3056950579
- Location
- Atlanta, GA · TIN 70-2461607
- 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 | $259.00 | $160.58 | — | — | DeniedCO29 |
| Totals | $259.00 | $160.58 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-505684
- 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-009987 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-22: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Fail | CO29 | Received 134 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Institute2025-09-22 10:23
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-03 04:41
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-03 11:28
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 134 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.