CLM-2026-033749
Valley Heart Institute, Cardiology. Service 2026-01-28 at outpatient hospital (POS 22). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Kenneth Hamilton
- Member ID
- UHC-66672-48
- Date of birth
- 1985-10-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428017
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6545
- Coverage period
- 2024-09-01 to present
- Deductible
- $741.82 of $1,000.0074%
- Out-of-pocket maximum
- $584.07 of $2,000.0029%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 3329237796
- Location
- Mesa, AZ · TIN 29-6624105
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,474.00 | $810.70 | — | — | DeniedCO18 |
| Totals | $1,474.00 | $810.70 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-469712
- 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-012294 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-28: N/A (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-033748: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Institute2026-01-28 13:40
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-03-02 03:25
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-469712.pdf3 pages
Itemised statement totalling $1474.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-033748: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033748 | 2026-01-28 | Valley Heart Institute | $1,474.00 | Approved |
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
Exact duplicate of an earlier submission.