Claims workbench/CLM-2026-028745
Institutional claim · UB-04 · Paper

CLM-2026-028745

Meadow Heart Institute, Cardiology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-02-09.

Pended
Billed
$8,369.00
1 line
Allowed
$4,602.95
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Lori Johnsson
Member ID
none on golden record
Date of birth
1990-01-12
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-428963
Relationship
Self, Charlotte, NC

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Meadow Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
7242507433
Network
In network
Rendering NPI
3537833170
Location
Dallas, TX · TIN 24-4567184
Authorisation / referral
PA2026293877 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193458
rev 0481
Cardiac catheterisation, left heart—11$8,369.00$4,602.95——PendedN30
Totals$8,369.00$4,602.95——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. I50.9 Heart failure, unspecified
Claim header
Patient account
PA-845145
Frequency code
1 (original)
Accident
No
DRG
287
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-011776 (provisional, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 33 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026293877 on file for 93458.
Provider networkPassIn-network provider Meadow Heart Institute (7242507433).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Heart Institute2026-01-07 09:48

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Prior auth letterPA2026293877_approval.pdf2 pages

    Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-07 to 2026-04-07.

  • Itemized billitemized_PA-845145.pdf9 pages

    Itemised statement totalling $8369.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0287462026-01-07Meadow Heart Institute$8,369.00Pended

AI recommendation

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

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

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity