Claims workbench/CLM-2026-024419
Professional claim · CMS-1500 · EDI 837P

CLM-2026-024419

Meadow Heart Institute, Cardiology. Service 2026-04-01 at office (POS 11). Received 2026-05-03.

Approved
Billed
$243.00
1 line
Allowed
$150.66
contract rate applied
Plan pays
$75.66
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Austin Yang
Member ID
UHC-35695-44
Date of birth
1983-07-18
Identity
Verified5 records, confidence 0.99
Claim record
CLMCLM-402376
Relationship
Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-7817
Coverage period
2025-03-01 to present
Deductible
$643.73 of $1,000.0064%
Out-of-pocket maximum
$851.62 of $3,000.0028%
Copays
office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits
0 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
3037628401
Network
In network
Rendering NPI
2743555411
Location
Los Angeles, CA · TIN 16-4907059
Authorisation / referral
none / REF939288

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$243.00$150.66$75.00$75.66Paid
Totals$243.00$150.66$75.00$75.66
Diagnoses (ICD-10-CM)
  • 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-524604
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

CheckResultCodeDetail
Member identityPassAttached to MBR-021663 (verified, link confidence 0.99).
EligibilityPassActive on 2026-04-01: CORE-HMO (HMO), effective 2025-03-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Heart Institute (3037628401).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Heart Institute2026-04-01 10:19

    Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$243.00
Plan discount
$92.34
contracted rate
Plan paid
$75.66
You may owe
$75.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0085362026-04-08Northgate Medical Group$433.00Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity