CLM-2026-030553
Meadow Heart Institute, Cardiology. Service 2026-09-11 at outpatient hospital (POS 22). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Valentina Olson
- Member ID
- UHC-29563-18
- Date of birth
- 1955-12-12
- Identity
- Verified2 records, confidence 0.94
- Claim record
- CLMCLM-418159
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5247
- Coverage period
- 2025-01-01 to present
- Deductible
- $980.71 of $1,500.0065%
- Out-of-pocket maximum
- $509.29 of $4,500.0011%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1132669718
- Network
- Out of network
- Rendering NPI
- 3783288897
- Location
- Houston, TX · TIN 84-3778444
- Authorisation / referral
- none / 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,458.00 | $656.10 | — | — | DeniedCO204 |
| Totals | $1,458.00 | $656.10 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-172561
- 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-031166 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-09-11: SELECT-EPO (EPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 35 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 | Fail | CO204 | Billing provider 1132669718 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Heart Institute2026-09-11 14:19
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-16 04:49
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-16 14:11
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-172561.pdf3 pages
Itemised statement totalling $1458.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1132669718 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.