CLM-2026-030801
Northgate Heart Institute, Cardiology. Service 2026-02-04 at outpatient hospital (POS 22). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Cynthia Santiago
- Member ID
- UHC-06856-30
- Date of birth
- 2006-03-09
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-425524
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0476
- Coverage period
- 2024-08-01 to present
- Deductible
- $16.11 of $2,500.001%
- Out-of-pocket maximum
- $2,472.64 of $5,000.0049%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 7386442801
- 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 | $512.00 | $281.60 | $281.60 | $0.00 | Paid |
| Totals | $512.00 | $281.60 | $281.60 | $0.00 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-490386
- 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-014469 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-04: CHOICE-PLUS-PPO (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 16 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 Institute2026-02-04 13:46
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Itemized billitemized_PA-490386.pdf8 pages
Itemised statement totalling $512.00 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
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.