Professional claim · CMS-1500 · EDI 837P
CLM-2026-006519
Meadow Heart Institute, Cardiology. Service 2026-02-07 at office (POS 11). Received 2026-02-20.
Approved
Billed
$253.00
1 line
Allowed
$156.86
contract rate applied
Plan pays
$96.86
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Yuki Richardson
- Member ID
- UHC-64259-10
- Date of birth
- 1982-02-08
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-403226
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0444
- Coverage period
- 2024-12-01 to present
- Deductible
- $21.38 of $2,500.001%
- Out-of-pocket maximum
- $2,251.88 of $7,500.0030%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- 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
- 8086313367
- Location
- Los Angeles, CA · TIN 16-4907059
- Authorisation / referral
- none / REF364532
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $253.00 | $156.86 | $60.00 | $96.86 | Paid |
| Totals | $253.00 | $156.86 | $60.00 | $96.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-262301
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002539 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-02-07: NAVIGATE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 13 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Heart Institute2026-02-07 15:36
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$253.00
Plan discount
$96.14
contracted rate
Plan paid
$96.86
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031927 | 2026-03-20 | Harbor Rehabilitation Center | $498.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.