CLM-2026-033413
Valley Heart Institute, Cardiology. Service 2026-04-01 at outpatient hospital (POS 22). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Sandra White
- Member ID
- UHC-73374-01
- Date of birth
- 1941-03-24
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-418948
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5611
- Coverage period
- 2025-03-01 to present
- Deductible
- $244.71 of $500.0049%
- Out-of-pocket maximum
- $310.58 of $2,000.0016%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- 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
- 3697814861
- Location
- Atlanta, GA · TIN 70-2461607
- Authorisation / referral
- none / REF748480
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 | $900.00 | $495.00 | $279.26 | $215.74 | Paid |
| Totals | $900.00 | $495.00 | $279.26 | $215.74 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-915473
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000887 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-01: NAVIGATE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| 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 Institute2026-04-01 13:11
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-915473.pdf5 pages
Itemised statement totalling $900.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.