Claims workbench/CLM-2026-018172

Institutional claim · UB-04 · EDI 837I

CLM-2026-018172

Meadow Heart Institute, Cardiology. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-03-20.

Denied

Billed

$9,295.00

2 lines

Allowed

$5,112.25

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Luis Dominguez
Member ID: UHC-85052-29
Date of birth: 1955-05-24
Identity: Verified5 records, confidence 1.00
Claim record: CLMCLM-425741
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-7179
Coverage period: 2024-06-01 to present
Deductible: $357.05 of $3,500.0010%
Out-of-pocket maximum: $2,125.73 of $7,000.0030%
Copays: office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 3037628401
Network: In network
Rendering NPI: 8690132716
Location: Los Angeles, CA · TIN 16-4907059
Authorisation / referral: PA2025082512 / 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	$955.00	$525.25	—	—	DeniedCO18
2	93458 rev 0481	Cardiac catheterisation, left heart	—	1	2	$8,340.00	$4,587.00	—	—	DeniedCO18
Totals						$9,295.00	$5,112.25	—	—

Diagnoses (ICD-10-CM)

1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
2. I10 Essential (primary) hypertension
3. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-198676
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-016468 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-01-25: SELECT-EPO (EPO), effective 2024-06-01.
Timely filing	Pass		Received 54 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-018171: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025082512 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow Heart Institute2026-01-25 18:06
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
SystemSystem: Claims system2026-03-20 01:34
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-20 10:51
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025082512_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-01-25 to 2026-04-25.
Itemized billitemized_PA-198676.pdf8 pages
Itemised statement totalling $9295.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-018171: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-006029	2026-04-29	Lakeside Internal Medicine Associates	$341.00	Denied
CLM-2026-018684	2026-08-12	Valley Digestive Health Center	$2,727.00	Approved
CLM-2026-029813	2026-03-03	Valley Community Hospital	$2,629.00	Needs review
CLM-2026-018171	2026-01-25	Meadow Heart Institute	$9,295.00	Approved

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity