CLM-2026-032533
Valley Heart Institute, Cardiology. Service 2026-02-17 at office (POS 11). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Carl Chapman
- Member ID
- UHC-14869-57
- Date of birth
- 1972-03-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428904
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2890
- Coverage period
- 2022-03-01 to 2026-03-05
- Deductible
- $1,327.03 of $1,500.0088%
- Out-of-pocket maximum
- $1,070.35 of $3,000.0036%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 6339021407
- Location
- Atlanta, GA · TIN 70-2461607
- Authorisation / referral
- none / REF179637
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $280.00 | $173.60 | — | — | DeniedCO29 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $293.00 | $181.66 | — | — | DeniedCO29 |
| Totals | $573.00 | $355.26 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-836732
- 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-034227 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-17: CORE-HMO (HMO), effective 2022-03-01, terms 2026-03-05. | |
| Timely filing | Fail | CO29 | Received 205 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 | 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 Institute2026-02-17 09:51
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-10 06:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-10 10:45
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 205 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.