CLM-2026-034025
Northgate Cardiovascular Associates, Cardiology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Charles Kelly
- Member ID
- UHC-86006-63
- Date of birth
- 2006-07-14
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-415536
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5937
- Coverage period
- 2024-01-01 to 2026-03-20
- Deductible
- $507.93 of $1,000.0051%
- Out-of-pocket maximum
- $181.03 of $3,000.006%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 3805323136
- Location
- Los Angeles, CA · TIN 22-8335037
- 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 | $465.00 | $255.75 | — | — | DeniedCO27 |
| Totals | $465.00 | $255.75 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-185160
- 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-009297 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-06 is after coverage terminated on 2026-03-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Northgate Cardiovascular Associates (5594465275). | |
| 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 Associates2026-08-06 15:00
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-27 03:25
Attachments
Documents received with the claim
- Itemized billitemized_PA-185160.pdf4 pages
Itemised statement totalling $465.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-06 is after coverage terminated on 2026-03-20.
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
Service after coverage termination.