CLM-2026-019406
Meadow Heart Institute, Cardiology. Service 2025-10-06 at outpatient hospital (POS 22). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Ashley Brooks
- Member ID
- UHC-93298-79
- Date of birth
- 1991-03-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407589
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1480
- Coverage period
- 2024-08-01 to present
- Deductible
- $69.68 of $500.0014%
- Out-of-pocket maximum
- $342.45 of $1,000.0034%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 3818883993
- Location
- Dallas, TX · TIN 24-4567184
- Authorisation / referral
- PA2026939574 / 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 | $4,938.00 | $2,715.90 | — | — | DeniedCO29 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $994.00 | $546.70 | — | — | DeniedCO29 |
| Totals | $5,932.00 | $3,262.60 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-640524
- 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-016567 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-06: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Fail | CO29 | Received 215 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026939574 on file for 93458. | |
| Provider network | Pass | In-network provider Meadow Heart Institute (7242507433). | |
| 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 Institute2025-10-06 13:15
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
- SystemSystem: Claims system2026-05-09 00:05
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-09 15:58
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026939574_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2025-10-06 to 2026-01-04.
- Itemized billitemized_PA-640524.pdf8 pages
Itemised statement totalling $5932.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 215 days after the last date of service (limit 90).
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
Received after the timely-filing limit.