CLM-2026-026566
Meadow Heart Institute, Cardiology. Service 2026-01-19 at outpatient hospital (POS 22). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Laura Perkins
- Member ID
- UHC-63015-71
- Date of birth
- 1956-09-28
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-406053
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9529
- Coverage period
- 2024-04-01 to present
- Deductible
- $293.85 of $1,500.0020%
- Out-of-pocket maximum
- $1,963.52 of $6,000.0033%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 9370944701
- Location
- Dallas, TX · TIN 24-4567184
- Authorisation / referral
- PA2026141775 / 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 | $7,620.00 | $4,191.00 | — | — | DeniedCO29 |
| Totals | $7,620.00 | $4,191.00 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-678999
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030492 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-19: MEDICARE-ADV-B (MA), effective 2024-04-01. | |
| Timely filing | Fail | CO29 | Received 114 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026141775 on file for 93458. | |
| 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 Institute2026-01-19 11:04
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-13 00:44
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026141775_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-19 to 2026-04-19.
- Itemized billitemized_PA-678999.pdf3 pages
Itemised statement totalling $7620.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 114 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002773 | 2026-06-05 | Evergreen Medical Group | $337.00 | Approved |
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
Received after the timely-filing limit.