CLM-2026-010564
Meadow Heart Institute, Cardiology. Service 2026-02-06 at outpatient hospital (POS 22). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Carolyn Harrison
- Member ID
- none on golden record
- Date of birth
- 1998-09-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414313
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-4080
- Coverage period
- 2023-08-01 to present
- Deductible
- $200.04 of $500.0040%
- Out-of-pocket maximum
- $275.23 of $1,000.0028%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 3781240239
- Location
- Houston, TX · TIN 84-3778444
- 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 | $544.00 | $244.80 | — | — | DeniedCO204 |
| Totals | $544.00 | $244.80 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-390647
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-000935; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-02-06: SELECT-EPO (EPO), effective 2023-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 16 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 | 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 Institute2026-02-06 12:00
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-22 03:34
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
- Itemized billitemized_PA-390647.pdf9 pages
Itemised statement totalling $544.00 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-000935; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-06: SELECT-EPO (EPO), effective 2023-08-01. 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.