Claims workbench/CLM-2026-028031

Professional claim · CMS-1500 · Paper

CLM-2026-028031

Meadow Heart Institute, Cardiology. Service 2026-03-20 at office (POS 11). Received 2026-10-13.

Denied

Billed

$630.00

2 lines

Allowed

$390.60

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Lucia Gomez
Member ID: UHC-42126-16
Date of birth: 1997-02-02
Identity: Verified4 records, confidence 0.96
Claim record: CLMCLM-430693
Relationship: Self, Gilbert, AZ

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-9339
Coverage period: 2023-04-01 to present
Deductible: $140.92 of $500.0028%
Out-of-pocket maximum: $30.28 of $2,000.002%
Copays: office $30.00, specialist $40.00, emergency $150.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 3037628401
Network: In network
Rendering NPI: 1949872760
Location: Los Angeles, CA · TIN 16-4907059
Authorisation / referral: none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99214	Office visit, established patient, moderate complexity	—	1	1	$308.00	$190.96	—	—	DeniedCO29
2	93224	Holter monitor, 48 hours	—	1	2	$322.00	$199.64	—	—	DeniedCO29
Totals						$630.00	$390.60	—	—

Diagnoses (ICD-10-CM)

1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-145694
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-003739 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-03-20: OPTIONS-PPO (PPO), effective 2023-04-01.
Timely filing	Fail	CO29	Received 207 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		No line requires precertification.
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow Heart Institute2026-03-20 14:07
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-10-13 05:49
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-13 09:36
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 207 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-011727	2026-07-20	Mesa Internal Medicine Associates	$65.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity