CLM-2026-016404
Meadow Cardiovascular Associates, Cardiology. Service 2026-01-26 at outpatient hospital (POS 22). Received 2026-02-07.
Member
Resolved through the identity graph
- Member
- Wayne Lee
- Member ID
- UHC-57483-83
- Date of birth
- 1949-01-02
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-421806
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0957
- Coverage period
- 2025-04-01 to present
- Deductible
- $831.58 of $1,000.0083%
- Out-of-pocket maximum
- $445.62 of $4,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 8180484478
- Network
- In network
- Rendering NPI
- 4261203614
- Location
- Scottsdale, AZ · TIN 33-6309233
- Authorisation / referral
- none / REF238000
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 | $652.00 | $358.60 | $225.47 | $133.13 | Paid |
| Totals | $652.00 | $358.60 | $225.47 | $133.13 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-842913
- 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-007147 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-26: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 12 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 Cardiovascular Associates (8180484478). | |
| 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 Cardiovascular Associates2026-01-26 14:23
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-842913.pdf4 pages
Itemised statement totalling $652.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004279 | 2026-03-18 | Pinecrest GI Associates | $2,179.00 | Denied |
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.