CLM-2026-018644
Meadow Heart Institute, Cardiology. Service 2026-04-15 at outpatient hospital (POS 22). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Russell Lee
- Member ID
- UHC-71483-82
- Date of birth
- 1966-02-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-422810
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2086
- Coverage period
- 2022-03-01 to present
- Deductible
- $1,391.08 of $2,500.0056%
- Out-of-pocket maximum
- $1,660.48 of $7,500.0022%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 3118907179
- Location
- Houston, TX · TIN 84-3778444
- Authorisation / referral
- PA2026761405 / 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 | $5,525.00 | $2,486.25 | — | — | DeniedCO204 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,138.00 | $512.10 | — | — | DeniedCO204 |
| Totals | $6,663.00 | $2,998.35 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-798278
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021401 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: SELECT-EPO (EPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026761405 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 1132669718 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Institute2026-04-15 18:59
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-17 06:31
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-17 12:52
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026761405_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-04-15 to 2026-07-14.
- Itemized billitemized_PA-798278.pdf3 pages
Itemised statement totalling $6663.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 1132669718 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.