CLM-2026-032161
Meadow Heart Institute, Cardiology. Service 2026-05-04 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Alan Thompson
- Member ID
- UHC-77689-96
- Date of birth
- 1972-10-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-423737
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8982
- Coverage period
- 2023-04-01 to present
- Deductible
- $2,266.63 of $3,500.0065%
- Out-of-pocket maximum
- $307.03 of $7,000.004%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 7242507433
- Network
- In network
- Rendering NPI
- 7930087540
- Location
- Dallas, TX · TIN 24-4567184
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $421.00 | $231.55 | $231.55 | $0.00 | Paid |
| Totals | $421.00 | $231.55 | $231.55 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-764282
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002489 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-04: - (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 39 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 | 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 Institute2026-05-04 11:16
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-764282.pdf4 pages
Itemised statement totalling $421.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015205 | 2026-08-07 | Sunrise Physical Therapy | $9,644.00 | Needs review |
| CLM-2026-022996 | 2026-07-30 | Mesa Orthopedic Specialists | $237.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.