CLM-2026-022491
Meadow Heart Institute, Cardiology. Service 2025-11-19 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Pamela Matthews
- Member ID
- UHC-37090-99
- Date of birth
- 1990-07-12
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407400
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5198
- Coverage period
- 2024-01-01 to present
- Deductible
- $710.32 of $1,500.0047%
- Out-of-pocket maximum
- $991.79 of $6,000.0017%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 3082574237
- Location
- Dallas, TX · TIN 24-4567184
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,078.00 | $592.90 | $592.90 | $0.00 | Paid |
| Totals | $1,078.00 | $592.90 | $592.90 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-591865
- 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-000234 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-19: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 43 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 Institute2025-11-19 09:35
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-591865.pdf6 pages
Itemised statement totalling $1078.00 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-2026-012344 | 2026-06-27 | Meadow Family Practice | $505.00 | Approved |
| CLM-2026-018340 | 2026-04-26 | Meadow Diagnostic Imaging | $2,422.00 | Needs review |
| CLM-2026-022492 | 2025-11-19 | Cornerstone Cardiovascular Associates | $1,078.00 | Needs review |
| CLM-2026-025821 | 2025-12-24 | Harbor Reference Lab | $52.00 | 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.