Claims workbench/CLM-2026-029644
Institutional claim · UB-04 · EDI 837I

CLM-2026-029644

Meadow Cardiovascular Associates, Cardiology. Service 2026-06-02 at outpatient hospital (POS 22). Received 2026-06-28.

Approved
Billed
$623.00
1 line
Allowed
$342.65
contract rate applied
Plan pays
$0.00
approved
Member owes
$342.65
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Alexis Jimenez
Member ID
UHC-20281-74
Date of birth
1971-09-20
Identity
Verified4 records, confidence 1.00
Claim record
CLMCLM-418695
Relationship
Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-0637
Coverage period
2021-10-01 to present
Deductible
$2,141.44 of $2,500.0086%
Out-of-pocket maximum
$960.33 of $7,500.0013%
Copays
office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits
6 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI
8180484478
Network
In network
Rendering NPI
7441913986
Location
Scottsdale, AZ · TIN 33-6309233
Authorisation / referral
none / REF497625

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193015Cardiovascular stress test—11$623.00$342.65$342.65$0.00Paid
Totals$623.00$342.65$342.65$0.00
Diagnoses (ICD-10-CM)
  • 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
Claim header
Patient account
PA-619838
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-005175 (verified, link confidence 1.00).
EligibilityPassActive on 2026-06-02: CORE-HMO (HMO), effective 2021-10-01.
Timely filingPassReceived 26 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Cardiovascular Associates (8180484478).
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. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Cardiovascular Associates2026-06-02 15:13

    Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-619838.pdf4 pages

    Itemised statement totalling $623.00 across 1 line.

Explanation of benefits

What the member will see

Amount billed
$623.00
Plan discount
$280.35
contracted rate
Plan paid
$0.00
You may owe
$342.65
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

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