CLM-2026-008544
Meadow Heart Institute, Cardiology. Service 2026-04-15 at outpatient hospital (POS 22). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Frank James
- Member ID
- none on golden record
- Date of birth
- 1954-05-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417666
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-9168
- Coverage period
- 2024-04-01 to present
- Deductible
- $2,189.86 of $2,500.0088%
- Out-of-pocket maximum
- $2,853.25 of $7,500.0038%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 6626232907
- Location
- Houston, TX · TIN 84-3778444
- Authorisation / referral
- PA2025254540 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $9,266.00 | $4,169.70 | — | — | DeniedCO204 |
| Totals | $9,266.00 | $4,169.70 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-436000
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003459; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-15: SELECT-EPO (EPO), effective 2024-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025254540 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 1132669718 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Institute2026-04-15 16:09
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-19 01:42
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025254540_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-04-15 to 2026-07-14.
- Itemized billitemized_PA-436000.pdf7 pages
Itemised statement totalling $9266.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-003459; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-15: SELECT-EPO (EPO), effective 2024-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 1132669718 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.