CLM-2026-029917
Northgate Heart Institute, Cardiology. Service 2026-05-01 at outpatient hospital (POS 22). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Abby Vazquez
- Member ID
- UHC-43328-08
- Date of birth
- 1966-07-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406445
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5748
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,197.20 of $3,500.0034%
- Out-of-pocket maximum
- $2,687.39 of $14,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 9526122293
- Location
- San Diego, CA · TIN 46-7688844
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $604.00 | $332.20 | $332.20 | $0.00 | Paid |
| Totals | $604.00 | $332.20 | $332.20 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-319323
- 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-011460 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-01: OPTIONS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 17 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 Heart Institute (5192135197). | |
| 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 Heart Institute2026-05-01 13:21
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-319323.pdf2 pages
Itemised statement totalling $604.00 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-2026-025974 | 2026-07-21 | Meadow Primary Care Associates | $144.00 | Needs review |
| CLM-2026-009243 | 2025-12-30 | Lakeside Bone and Joint Center | $37,943.00 | 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.