Claims workbench/CLM-2026-028746

Institutional claim · UB-04 · Paper

CLM-2026-028746

Meadow Heart Institute, Cardiology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-02-19.

PendedReplacement of CLM-2026-028745

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

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	93458 rev 0481	Cardiac catheterisation, left heart	—	1	1	$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-927081
Frequency code: 7 (replacement)
Accident: No
DRG: 287
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-011776 (provisional, link confidence 1.00).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 43 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-028745; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		Authorisation PA2026293877 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.

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 17:14
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-02-19 03:00
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-19 16:06
Reviewed with the member's history on file. Holding for the items listed above.

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-927081.pdf6 pages
Itemised statement totalling $8369.00 across 1 line.
Corrected claimcorrected_CLM-2026-028745.pdf1 page
Provider cover letter requesting replacement of CLM-2026-028745.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Replacement claim: Frequency code 7 replaces CLM-2026-028745; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-028745	2026-01-07	Meadow Heart Institute	$8,369.00	Pended

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

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity