CLM-2026-031451
Northgate Heart Institute, Cardiology. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Samantha Obrien
- Member ID
- UHC-10855-85
- Date of birth
- 1965-02-22
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-413451
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2721
- Coverage period
- 2022-05-01 to present
- Deductible
- $371.02 of $1,000.0037%
- Out-of-pocket maximum
- $1,983.29 of $4,000.0050%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 2457762468
- Location
- Los Angeles, CA · TIN 48-8536899
- 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 | $699.00 | $384.45 | $384.45 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1,2 | $1,153.00 | $634.15 | $361.42 | $272.73 | Paid |
| Totals | $1,852.00 | $1,018.60 | $745.87 | $272.73 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-543260
- 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-024042 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-06: OPTIONS-PPO (PPO), effective 2022-05-01. | |
| 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 (1929886434). | |
| 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 Institute2026-06-06 17:33
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-543260.pdf5 pages
Itemised statement totalling $1852.00 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-2026-011527 | 2026-07-05 | Harbor Rehabilitation Center | $206.00 | Approved |
| CLM-2026-016736 | 2026-06-22 | Pinecrest Medical Group | $82.00 | Approved |
| CLM-2026-024108 | 2026-02-26 | Canyon Counseling Center | $191.00 | Approved |
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.