CLM-2026-034601
Valley Heart Institute, Cardiology. Service 2026-01-19 at outpatient hospital (POS 22). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Gary Fields
- Member ID
- UHC-65382-80
- Date of birth
- 1988-08-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426590
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7846
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,119.12 of $3,500.0032%
- Out-of-pocket maximum
- $2,132.54 of $7,000.0030%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 3951070705
- Location
- Mesa, AZ · TIN 29-6624105
- Authorisation / referral
- PA2025243742 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,466.00 | $1,906.30 | — | — | Review |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $350.00 | $192.50 | — | — | Review |
| Totals | $3,816.00 | $2,098.80 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-154988
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-013658 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-19: OPTIONS-PPO (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025243742 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Heart Institute (9412184639). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Institute2026-01-19 18:14
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-02-17 06:50
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-17 09:38
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025243742_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-19 to 2026-04-19.
- Itemized billitemized_PA-154988.pdf8 pages
Itemised statement totalling $3816.00 across 2 lines.
- Medical recordrecords_PA-154988.pdf10 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004617 | 2026-09-14 | Unity Primary Care Associates | $236.00 | Approved |
| CLM-2026-012628 | 2026-09-03 | Sunrise Digestive Health Center | $3,858.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Notes document medical necessity.