CLM-2026-017732
Meadow Cardiovascular Associates, Cardiology. Service 2026-07-28 at outpatient hospital (POS 22). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Judith Jenkins
- Member ID
- none on golden record
- Date of birth
- 1971-08-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427137
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-9520
- Coverage period
- 2023-05-01 to 2026-07-16
- Deductible
- $249.78 of $1,000.0025%
- Out-of-pocket maximum
- $688.33 of $2,000.0034%
- Copays
- office $25.00, 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
- 2145896462
- Network
- In network
- Rendering NPI
- 6318793273
- Location
- Scottsdale, AZ · TIN 58-0592913
- Authorisation / referral
- PA2026238705 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,286.00 | $4,557.30 | — | — | DeniedCO27 |
| Totals | $8,286.00 | $4,557.30 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-408574
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-002398; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-07-28 is after coverage terminated on 2026-07-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026238705 on file for 93458. | |
| Provider network | Pass | In-network provider Meadow Cardiovascular Associates (2145896462). | |
| 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 Associates2026-07-28 12:14
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-11 06:52
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-11 15:24
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026238705_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-07-28 to 2026-10-26.
- Itemized billitemized_PA-408574.pdf3 pages
Itemised statement totalling $8286.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-002398; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-07-28 is after coverage terminated on 2026-07-16.
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
Service after coverage termination.