CLM-2026-005108
Meadow Heart Institute, Cardiology. Service 2026-02-12 at outpatient hospital (POS 22). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Melissa Maldonado
- Member ID
- UHC-80701-58
- Date of birth
- 1971-06-16
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-430129
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5911
- Coverage period
- 2021-06-01 to present
- Deductible
- $374.38 of $500.0075%
- Out-of-pocket maximum
- $203.09 of $2,000.0010%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 4058979194
- Location
- Los Angeles, CA · TIN 16-4907059
- Authorisation / referral
- none / REF135369
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 | $580.00 | $319.00 | $164.30 | $154.70 | Paid |
| Totals | $580.00 | $319.00 | $164.30 | $154.70 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-743429
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010141 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-12: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 23 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 Institute2026-02-12 13:06
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-743429.pdf8 pages
Itemised statement totalling $580.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011463 | 2026-07-20 | Pinecrest Bone and Joint Center | $9,982.00 | Denied |
| CLM-2026-011346 | 2026-03-16 | Canyon Reference Lab | $49.00 | Approved |
| CLM-2026-025462 | 2025-12-26 | Sunrise Cardiovascular Associates | $1,909.00 | Denied |
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.