Claims workbench/CLM-2026-016665
Institutional claim · UB-04 · Provider portal

CLM-2026-016665

Meadow Cardiovascular Associates, Cardiology. Service 2026-02-14 at outpatient hospital (POS 22). Received 2026-02-16.

PendedIdentity on hold: CASE-001533
Billed
$8,125.00
1 line
Allowed
$4,468.75
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Grace Soto
Member ID
none on golden record
Date of birth
1947-03-03
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-400363
Relationship
Self, Orlando, FL

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Meadow Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI
8180484478
Network
In network
Rendering NPI
3022199608
Location
Scottsdale, AZ · TIN 33-6309233
Authorisation / referral
PA2025101216 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193458
rev 0481
Cardiac catheterisation, left heart—11$8,125.00$4,468.75——PendedIDQ
Totals$8,125.00$4,468.75——
Diagnoses (ICD-10-CM)
  • 1. I48.91 Unspecified atrial fibrillationprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-576349
Frequency code
1 (original)
Accident
No
DRG
287
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-001533; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2025101216 on file for 93458.
Provider networkPassIn-network provider Meadow Cardiovascular Associates (8180484478).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Cardiovascular Associates2026-02-14 12:15

    Patient seen for unspecified atrial fibrillation.

Attachments

Documents received with the claim

  • Prior auth letterPA2025101216_approval.pdf2 pages

    Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-02-14 to 2026-05-15.

  • Itemized billitemized_PA-576349.pdf7 pages

    Itemised statement totalling $8125.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-001533; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity