CLM-2026-021816
Meadow Heart Institute, Cardiology. Service 2026-06-08 at outpatient hospital (POS 22). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Jason Rogers
- Member ID
- UHC-81029-91
- Date of birth
- 1955-10-21
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-432100
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4419
- Coverage period
- 2021-11-01 to 2026-07-01
- Deductible
- $926.92 of $1,500.0062%
- Out-of-pocket maximum
- $1,130.75 of $3,000.0038%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 1540150913
- Location
- Dallas, TX · TIN 24-4567184
- Authorisation / referral
- none / REF539072
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 | $1,483.00 | $815.65 | $645.85 | $169.80 | Paid |
| Totals | $1,483.00 | $815.65 | $645.85 | $169.80 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-166406
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015622 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-08: NAVIGATE-HMO (HMO), effective 2021-11-01, terms 2026-07-01. | |
| 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 (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 Institute2026-06-08 17:36
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-166406.pdf9 pages
Itemised statement totalling $1483.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017394 | 2026-02-07 | Lakeside Physical Therapy | $171.00 | Approved |
| CLM-2026-027282 | 2026-02-13 | Meadow Family Practice | $207.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.