CLM-2026-032638
Northgate Cardiovascular Associates, Cardiology. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Gregory Kennedy
- Member ID
- UHC-80526-03
- Date of birth
- 1991-09-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422387
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3592
- Coverage period
- 2024-10-01 to present
- Deductible
- $258.22 of $500.0052%
- Out-of-pocket maximum
- $297.03 of $1,000.0030%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 7788544188
- Network
- In network
- Rendering NPI
- 2456231911
- Location
- Denver, CO · TIN 90-6939418
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,178.00 | $2,847.90 | — | — | DeniedCO197 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $595.00 | $327.25 | — | — | DeniedCO197 |
| Totals | $5,773.00 | $3,175.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-103932
- 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-014890 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-21: OPTIONS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (7788544188). | |
| 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 Cardiovascular Associates2026-08-21 12:11
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-09-24 00:18
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-103932.pdf4 pages
Itemised statement totalling $5773.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025909 | 2026-08-31 | Lakeside Imaging Center | $2,184.00 | Needs review |
| CLM-2026-025908 | 2026-08-31 | Desert Imaging Center | $2,184.00 | Needs review |
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
Precertification required and absent.