CLM-2026-030170
Desert Cardiovascular Associates, Cardiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Kathleen Rogers
- Member ID
- UHC-53818-07
- Date of birth
- 1951-05-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404603
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group N/A
- Coverage period
- 2022-07-01 to present
- Deductible
- $113.74 of $1,500.008%
- Out-of-pocket maximum
- $37.41 of $4,500.001%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5097822972
- Network
- In network
- Rendering NPI
- 2978614313
- Location
- Mesa, AZ · TIN 54-0867004
- Authorisation / referral
- PA2026909618 / 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 | $5,377.00 | $2,957.35 | $1,857.59 | $1,099.76 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,091.00 | $600.05 | $180.02 | $420.03 | Paid |
| 3 | 93015 | Cardiovascular stress test | — | 1 | 1 | $583.00 | $320.65 | $96.20 | $224.45 | Paid |
| Totals | $7,051.00 | $3,878.05 | $2,133.81 | $1,744.24 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-505895
- 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-005615 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-08: SELECT-EPO (EPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026909618 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Cardiovascular Associates (5097822972). | |
| 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: Desert Cardiovascular Associates2026-01-08 09:32
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026909618_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-505895.pdf8 pages
Itemised statement totalling $7051.00 across 3 lines.
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
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.