CLM-2026-026814
Meadow Heart Institute, Cardiology. Service 2026-02-05 at outpatient hospital (POS 22). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Diane Rivera
- Member ID
- UHC-27906-92
- Date of birth
- 1978-09-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401128
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2024-05-01 to present
- Deductible
- $266.31 of $500.0053%
- Out-of-pocket maximum
- $409.57 of $1,500.0027%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 5743091329
- Location
- Houston, TX · TIN 84-3778444
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $655.00 | $294.75 | $239.80 | $54.95 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | 25 | 1 | 1 | $1,352.00 | $608.40 | $60.84 | $547.56 | Paid |
| Totals | $2,007.00 | $903.15 | $300.64 | $602.51 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-464120
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-012613 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-05: N/A (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 7 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Institute2026-02-05 09:17
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-464120.pdf4 pages
Itemised statement totalling $2007.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.