CLM-2026-031476
Meadow Heart Institute, Cardiology. Service 2026-08-14 at outpatient hospital (POS 22). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Marcus Cooper
- Member ID
- UHC-91372-60
- Date of birth
- 1952-08-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412357
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8061
- Coverage period
- 2024-06-01 to 2026-03-11
- Deductible
- $1,400.84 of $3,500.0040%
- Out-of-pocket maximum
- $2,945.72 of $10,500.0028%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 4962955397
- Location
- Dallas, TX · TIN 24-4567184
- Authorisation / referral
- PA2026341496 / 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 | $8,357.00 | $4,596.35 | — | — | DeniedCO27 |
| Totals | $8,357.00 | $4,596.35 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-125739
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-041901 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-14 is after coverage terminated on 2026-03-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026341496 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Heart Institute2026-08-14 10:16
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-08-18 02:14
Attachments
Documents received with the claim
- Prior auth letterPA2026341496_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-08-14 to 2026-11-12.
- Itemized billitemized_PA-125739.pdf8 pages
Itemised statement totalling $8357.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-14 is after coverage terminated on 2026-03-11.
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
Service after coverage termination.