CLM-2026-016754
Meadow Heart Institute, Cardiology. Service 2026-03-19 at outpatient hospital (POS 22). Received 2026-03-29.
Member
Resolved through the identity graph
- Member
- Dennis Warren
- Member ID
- UHC-83107-26
- Date of birth
- 1969-11-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426458
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7294
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,117.41 of $1,500.0074%
- Out-of-pocket maximum
- $1,445.63 of $4,500.0032%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 9931380940
- Location
- Houston, TX · TIN 84-3778444
- Authorisation / referral
- PA2026586605 / REF127221
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,504.00 | $1,126.80 | — | — | DeniedCO204 |
| Totals | $2,504.00 | $1,126.80 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-876873
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002718 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-19: NAVIGATE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026586605 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 1132669718 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Institute2026-03-19 13:28
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-29 01:34
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-29 16:59
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026586605_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-19 to 2026-06-17.
- Itemized billitemized_PA-876873.pdf2 pages
Itemised statement totalling $2504.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 1132669718 is out of network and the HMO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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.