CLM-2026-031967
Valley Heart Institute, Cardiology. Service 2026-04-18 at outpatient hospital (POS 22). Received 2026-07-24.
Member
Resolved through the identity graph
- Member
- Bobby Watson
- Member ID
- UHC-36535-02
- Date of birth
- 1997-02-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412436
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1299
- Coverage period
- 2021-02-01 to present
- Deductible
- $14.07 of $500.003%
- Out-of-pocket maximum
- $563.51 of $1,500.0038%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 3480726322
- Location
- Mesa, AZ · TIN 29-6624105
- Authorisation / referral
- PA2026632447 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,173.00 | $4,495.15 | — | — | DeniedCO29 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,472.00 | $809.60 | — | — | DeniedCO29 |
| Totals | $9,645.00 | $5,304.75 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-515043
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-039435 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-18: SELECT-EPO (EPO), effective 2021-02-01. | |
| Timely filing | Fail | CO29 | Received 97 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026632447 on file for 93458. | |
| Provider network | Pass | In-network provider Valley Heart Institute (9412184639). | |
| 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 Institute2026-04-18 10:07
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-24 03:49
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026632447_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-04-18 to 2026-07-17.
- Itemized billitemized_PA-515043.pdf6 pages
Itemised statement totalling $9645.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 97 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.