CLM-2026-013727
Meadow Heart Institute, Cardiology. Service 2026-10-05 at outpatient hospital (POS 22). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Amanda Guerrero
- Member ID
- UHC-02982-66
- Date of birth
- 2007-07-09
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-430718
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1534
- Coverage period
- 2022-12-01 to present
- Deductible
- $445.77 of $500.0089%
- Out-of-pocket maximum
- $7.49 of $1,000.001%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 6877533425
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $975.00 | $438.75 | $131.13 | $307.62 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $554.00 | $249.30 | $49.86 | $199.44 | Paid |
| Totals | $1,529.00 | $688.05 | $180.99 | $507.06 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-114962
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015203 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-10-05: CHOICE-PLUS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 2 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Institute2026-10-05 18:17
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-114962.pdf5 pages
Itemised statement totalling $1529.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013052 | 2026-05-09 | Desert Rehabilitation Center | $177.00 | Approved |
| CLM-2026-032238 | 2026-02-21 | Desert Family Practice | $265.00 | Approved |
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.