CLM-2026-004662
Meadow Heart Institute, Cardiology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-10-17.
Member
Resolved through the identity graph
- Member
- Juan Franklin
- Member ID
- UHC-92188-10
- Date of birth
- 1963-03-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415465
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7403
- Coverage period
- 2022-11-01 to 2026-05-01
- Deductible
- $394.84 of $1,000.0039%
- Out-of-pocket maximum
- $1,030.00 of $4,000.0026%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 8928762995
- Location
- Los Angeles, CA · TIN 16-4907059
- 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 | $1,412.00 | $776.60 | — | — | DeniedCO27 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $405.00 | $222.75 | — | — | DeniedCO27 |
| Totals | $1,817.00 | $999.35 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-547955
- 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-029389 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-05 is after coverage terminated on 2026-05-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 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 Meadow Heart Institute (3037628401). | |
| 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: Meadow Heart Institute2026-09-05 16:41
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-10-17 01:16
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-17 12:45
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-547955.pdf5 pages
Itemised statement totalling $1817.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-05 is after coverage terminated on 2026-05-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022376 | 2026-06-30 | Summit Counseling Center | $141.00 | Denied |
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.