CLM-2026-032830
Desert Cardiovascular Associates, Cardiology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Hannah Coleman
- Member ID
- UHC-98061-34
- Date of birth
- 1957-12-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401569
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7057
- Coverage period
- 2023-06-01 to present
- Deductible
- $137.67 of $500.0028%
- Out-of-pocket maximum
- $792.00 of $2,000.0040%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 1238878478
- Location
- Houston, TX · TIN 63-6537518
- 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 | $632.00 | $347.60 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,130.00 | $4,471.50 | — | — | DeniedCO197 |
| Totals | $8,762.00 | $4,819.10 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-692909
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006397 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-31: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 21 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 Desert Cardiovascular Associates (1421288352). | |
| 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: Desert Cardiovascular Associates2025-12-31 18:36
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-21 05:48
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-692909.pdf9 pages
Itemised statement totalling $8762.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
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
Precertification required and absent.