CLM-2026-030959
Unity Cardiovascular Associates, Cardiology. Service 2026-06-15 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Steve Wallace
- Member ID
- UHC-15113-79
- Date of birth
- 1940-10-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-427458
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9366
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,016.01 of $3,500.0029%
- Out-of-pocket maximum
- $4,921.76 of $14,000.0035%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2734278403
- Network
- In network
- Rendering NPI
- 2172838494
- Location
- Atlanta, GA · TIN 78-7453975
- Authorisation / referral
- none / REF706964
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 | $5,200.00 | $2,860.00 | — | — | DeniedCO197 |
| Totals | $5,200.00 | $2,860.00 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-291661
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-035405 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-15: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Cardiovascular Associates (2734278403). | |
| 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: Unity Cardiovascular Associates2026-06-15 10:01
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-22 06:11
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-22 08:11
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-291661.pdf3 pages
Itemised statement totalling $5200.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026751 | 2026-07-27 | Desert Primary Care Associates | $319.00 | Approved |
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
Precertification required and absent.