CLM-2026-017488
Meadow Cardiovascular Associates, Cardiology. Service 2026-07-25 at outpatient hospital (POS 22). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Eric Jimenez
- Member ID
- none on golden record
- Date of birth
- 1953-12-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401071
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-8377
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,217.54 of $3,500.0063%
- Out-of-pocket maximum
- $2,462.60 of $14,000.0018%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 8180484478
- Network
- In network
- Rendering NPI
- 4571929569
- Location
- Scottsdale, AZ · TIN 33-6309233
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $544.00 | $299.20 | — | — | PendedIDQ |
| Totals | $544.00 | $299.20 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-339642
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000927; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-25: OPTIONS-PPO (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 14 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 Associates2026-07-25 16:30
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Itemized billitemized_PA-339642.pdf8 pages
Itemised statement totalling $544.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000927; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-25: OPTIONS-PPO (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.