CLM-2026-030283
Riverside Cardiovascular Associates, Cardiology. Service 2026-09-08 at office (POS 11). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Ethan Williamson
- Member ID
- UHC-49331-36
- Date of birth
- 1984-12-10
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-428052
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1553
- Coverage period
- 2024-06-01 to 2026-01-25
- Deductible
- $53.01 of $500.0011%
- Out-of-pocket maximum
- $634.67 of $1,500.0042%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 1162603991
- Location
- Atlanta, GA · TIN 37-2658699
- 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 | $257.00 | $159.34 | — | — | DeniedCO27 |
| Totals | $257.00 | $159.34 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-175606
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021932 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-08 is after coverage terminated on 2026-01-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 Riverside Cardiovascular Associates (4236552608). | |
| 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: Riverside Cardiovascular Associates2026-09-08 18:41
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-04 00:40
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-08 is after coverage terminated on 2026-01-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031475 | 2026-06-27 | Cornerstone Internal Medicine Associates | $62.00 | Denied |
| CLM-2026-032740 | 2026-03-06 | Lakeside Internal Medicine Associates | $185.00 | Denied |
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
Service after coverage termination.