CLM-2026-007121
Meadow Heart Institute, Cardiology. Service 2026-01-28 at office (POS 11). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Pamela Baker
- Member ID
- UHC-97391-25
- Date of birth
- 1947-03-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428945
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6257
- Coverage period
- 2024-04-01 to present
- Deductible
- $1,290.84 of $2,500.0052%
- Out-of-pocket maximum
- $3,400.68 of $7,500.0045%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 6956708831
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $291.00 | $180.42 | — | — | Review |
| Totals | $291.00 | $180.42 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-149641
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018016 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-28: CHOICE-PLUS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 38 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 | Review | CO16 | Documentation incomplete: “Patient seen for essential (primary) hypertension. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Heart Institute2026-01-28 11:21
Patient seen for essential (primary) hypertension. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-07 00:58
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-07 16:07
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for essential (primary) hypertension. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025558 | 2026-02-19 | Cornerstone Digestive Health Center | $1,467.00 | Approved |
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
Development letter outstanding.