CLM-2026-026367
Meadow Heart Institute, Cardiology. Service 2026-08-13 at outpatient hospital (POS 22). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Denise Jackson
- Member ID
- UHC-63308-42
- Date of birth
- 1949-03-07
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-423988
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6609
- Coverage period
- 2025-01-01 to present
- Deductible
- $776.85 of $2,500.0031%
- Out-of-pocket maximum
- $3,040.50 of $10,000.0030%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 6855271246
- Location
- Houston, TX · TIN 84-3778444
- Authorisation / referral
- none / REF937566
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 | $1,251.00 | $562.95 | — | — | DeniedCO204 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $594.00 | $267.30 | — | — | DeniedCO204 |
| Totals | $1,845.00 | $830.25 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-511569
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010516 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-13: NAVIGATE-HMO (HMO), effective 2025-01-01. | |
| Timely filing | Pass | Received 34 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 | Fail | CO204 | Billing provider 1132669718 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Institute2026-08-13 18:57
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-09-16 06:31
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-511569.pdf5 pages
Itemised statement totalling $1845.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1132669718 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028292 | 2025-11-09 | Meadow Dermatology Clinic | $1,082.00 | Denied |
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
No out-of-network benefit on this plan.