CLM-2026-017030
Meadow Heart Institute, Cardiology. Service 2025-06-08 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Matthew Li
- Member ID
- UHC-62155-73
- Date of birth
- 1961-10-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418626
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3290
- Coverage period
- 2025-12-01 to present
- Deductible
- $475.43 of $1,000.0048%
- Out-of-pocket maximum
- $543.59 of $2,000.0027%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 4015271271
- Location
- Los Angeles, CA · TIN 16-4907059
- Authorisation / referral
- PA2025074052 / 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 | $994.00 | $546.70 | — | — | DeniedN30 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $5,260.00 | $2,893.00 | — | — | DeniedN30 |
| Totals | $6,254.00 | $3,439.70 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-592693
- 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-002059 (verified, link confidence 0.99). | |
| Eligibility | Fail | N30 | Date of service 2025-06-08 is before coverage effective date 2025-12-01. Patient ineligible for this service |
| Timely filing | Fail | CO29 | Received 213 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025074052 on file for 93458. | |
| Provider network | Pass | In-network provider Meadow Heart Institute (3037628401). | |
| 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 Institute2025-06-08 10:49
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-07 04:11
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2025074052_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2025-06-08 to 2025-09-06.
- Itemized billitemized_PA-592693.pdf8 pages
Itemised statement totalling $6254.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2025-06-08 is before coverage effective date 2025-12-01. Timely filing: Received 213 days after the last date of service (limit 90).
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
Received after the timely-filing limit.