CLM-2026-031218
Mesa Cardiovascular Associates, Cardiology. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Jessica Schmidt
- Member ID
- UHC-33321-26
- Date of birth
- 1999-11-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421118
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7314
- Coverage period
- 2023-08-01 to present
- Deductible
- $321.16 of $1,000.0032%
- Out-of-pocket maximum
- $1,572.89 of $4,000.0039%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4876629211
- Network
- In network
- Rendering NPI
- 8043466159
- Location
- Austin, TX · TIN 24-4510825
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,171.00 | $644.05 | $644.05 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $558.00 | $306.90 | $62.00 | $244.90 | Paid |
| Totals | $1,729.00 | $950.95 | $706.05 | $244.90 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-882842
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-008071 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-25: MEDICARE-ADV-B (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 2 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 Mesa Cardiovascular Associates (4876629211). | |
| 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: Mesa Cardiovascular Associates2026-01-25 12:19
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-882842.pdf8 pages
Itemised statement totalling $1729.00 across 2 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015634 | 2026-06-16 | Cornerstone Imaging Center | $2,381.00 | Needs review |
| CLM-2026-023601 | 2026-05-16 | Desert Cardiovascular Associates | $7,063.00 | Denied |
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.