CLM-2026-031622
Valley Heart Institute, Cardiology. Service 2026-07-31 at outpatient hospital (POS 22). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Ana Gibson
- Member ID
- UHC-12515-95
- Date of birth
- 1998-12-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406880
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5852
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,626.18 of $2,500.0065%
- Out-of-pocket maximum
- $2,306.09 of $5,000.0046%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 5366640345
- Location
- Atlanta, GA · TIN 70-2461607
- 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 | $1,089.00 | $598.95 | — | — | DeniedCO18 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $454.00 | $249.70 | — | — | DeniedCO18 |
| Totals | $1,543.00 | $848.65 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-487638
- 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-009099 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-31: MEDICARE-ADV-A (MA), effective 2022-11-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031621: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Heart Institute (1412691184). | |
| 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: Valley Heart Institute2026-07-31 18:27
Patient seen for heart failure, unspecified.
- SystemSystem: Claims system2026-09-09 05:14
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-09 14:25
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-487638.pdf4 pages
Itemised statement totalling $1543.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-031621: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031621 | 2026-07-31 | Valley Heart Institute | $1,543.00 | Approved |
| CLM-2026-031934 | 2026-05-06 | Pinecrest Internal Medicine Associates | $629.00 | 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
Exact duplicate of an earlier submission.