CLM-2026-025151
Meadow Heart Institute, Cardiology. Service 2026-08-25 at outpatient hospital (POS 22). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Carolyn Harrison
- Member ID
- UHC-59431-11
- Date of birth
- 1998-09-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414315
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4080
- Coverage period
- 2023-08-01 to present
- Deductible
- $200.04 of $500.0040%
- Out-of-pocket maximum
- $275.23 of $1,000.0028%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 7308101402
- Location
- Los Angeles, CA · TIN 16-4907059
- Authorisation / referral
- PA2025696352 / 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 | $7,319.00 | $4,025.45 | $1,045.06 | $2,980.39 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $465.00 | $255.75 | $51.15 | $204.60 | Paid |
| Totals | $7,784.00 | $4,281.20 | $1,096.21 | $3,184.99 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-574708
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003058 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-25: SELECT-EPO (EPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025696352 on file for 93458. | |
| Provider network | Pass | In-network provider Meadow Heart Institute (3037628401). | |
| 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 Institute2026-08-25 12:46
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025696352_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-25 to 2026-11-23.
- Itemized billitemized_PA-574708.pdf9 pages
Itemised statement totalling $7784.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022290 | 2026-07-31 | Mesa Family Practice | $178.00 | Approved |
| CLM-2026-024189 | 2025-12-28 | Lakeside Clinical Laboratories | $163.00 | 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.