CLM-2026-027406
Meadow Cardiovascular Associates, Cardiology. Service 2026-03-26 at outpatient hospital (POS 22). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Don Coleman
- Member ID
- UHC-72406-80
- Date of birth
- 1984-12-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404343
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4103
- Coverage period
- 2022-07-01 to present
- Deductible
- $2,905.19 of $3,500.0083%
- Out-of-pocket maximum
- $6,323.35 of $14,000.0045%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 8180484478
- Network
- In network
- Rendering NPI
- 2329222527
- Location
- Scottsdale, AZ · TIN 33-6309233
- Authorisation / referral
- none / REF799282
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 | $379.00 | $208.45 | $208.45 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,205.00 | $662.75 | $414.00 | $248.75 | Paid |
| Totals | $1,584.00 | $871.20 | $622.45 | $248.75 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-689181
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-026809 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-26: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 25 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 | Pass | In-network provider Meadow Cardiovascular Associates (8180484478). | |
| 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 Cardiovascular Associates2026-03-26 13:40
Patient seen for essential (primary) hypertension. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-04-20 02:16
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-689181.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-689181.pdf5 pages
Itemised statement totalling $1584.00 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
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
Authorisation must be confirmed with UM before payment.