CLM-2026-018367
Meadow Heart Institute, Cardiology. Service 2026-02-28 at outpatient hospital (POS 22). Received 2026-03-19.
Member
Resolved through the identity graph
- Member
- Danielle Young
- Member ID
- UHC-09608-97
- Date of birth
- 2004-09-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-429952
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0791
- Coverage period
- 2022-07-01 to present
- Deductible
- $564.74 of $1,500.0038%
- Out-of-pocket maximum
- $1,330.60 of $6,000.0022%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 4600736126
- Location
- Los Angeles, CA · TIN 16-4907059
- 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 | 59 | 1 | 1 | $601.00 | $330.55 | — | — | Review |
| 2 | 93306 rev 0480 | Echocardiogram, complete | 59 | 1 | 1 | $1,216.00 | $668.80 | — | — | Review |
| Totals | $1,817.00 | $999.35 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-102821
- 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-020602 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-28: CORE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 19 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 Heart Institute (3037628401). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Institute2026-02-28 12:45
Patient seen for unspecified atrial fibrillation. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-03-19 03:23
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Itemized billitemized_PA-102821.pdf2 pages
Itemised statement totalling $1817.00 across 2 lines.
- Medical recordrecords_PA-102821.pdf9 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Bundled code pair; modifier 59 not supported by the operative note.