CLM-2026-005718
Meadow Heart Institute, Cardiology. Service 2026-02-16 at office (POS 11). Received 2026-09-18.
Member
Resolved through the identity graph
- Member
- Judy Schmidt
- Member ID
- UHC-15358-33
- Date of birth
- 1998-11-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419425
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2291
- Coverage period
- 2025-12-01 to 2026-08-27
- Deductible
- $475.86 of $1,000.0048%
- Out-of-pocket maximum
- $160.31 of $2,000.008%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 7982053655
- Location
- Los Angeles, CA · TIN 16-4907059
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $423.00 | $262.26 | — | — | DeniedCO29 |
| Totals | $423.00 | $262.26 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-229510
- 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-025254 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-16: MEDICARE-ADV-B (MA), effective 2025-12-01, terms 2026-08-27. | |
| Timely filing | Fail | CO29 | Received 214 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Institute2026-02-16 09:52
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-18 02:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 214 days after the last date of service (limit 90).
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
Received after the timely-filing limit.