CLM-2026-010413
Meadow Heart Institute, Cardiology. Service 2026-04-04 at outpatient hospital (POS 22). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Juan Nunez
- Member ID
- UHC-78483-83
- Date of birth
- 1952-05-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426917
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8364
- Coverage period
- 2022-07-01 to present
- Deductible
- $172.49 of $500.0034%
- Out-of-pocket maximum
- $85.01 of $2,000.004%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 7874195457
- Location
- Dallas, TX · TIN 24-4567184
- Authorisation / referral
- none / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $600.00 | $330.00 | $328.26 | $1.74 | Paid |
| Totals | $600.00 | $330.00 | $328.26 | $1.74 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-889213
- 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-028842 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-04: N/A (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 28 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 (7242507433). | |
| 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 Institute2026-04-04 09:54
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-889213.pdf7 pages
Itemised statement totalling $600.00 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
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.