CLM-2026-034019
Meadow Heart Institute, Cardiology. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-04-24.
Member
Resolved through the identity graph
- Member
- Joan Hughes
- Member ID
- UHC-74801-99
- Date of birth
- 1989-03-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-408253
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7170
- Coverage period
- 2024-04-01 to present
- Deductible
- $688.45 of $1,500.0046%
- Out-of-pocket maximum
- $2,991.48 of $6,000.0050%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3037628401
- Network
- In network
- Rendering NPI
- 3063082705
- Location
- Los Angeles, CA · TIN 16-4907059
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,216.00 | $2,868.80 | — | — | DeniedCO197 |
| Totals | $5,216.00 | $2,868.80 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-810110
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-027449 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-29: MEDICARE-ADV-B (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Meadow Heart Institute (3037628401). | |
| 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 Institute2026-03-29 12:12
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
- SystemSystem: Claims system2026-04-24 06:11
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-810110.pdf2 pages
Itemised statement totalling $5216.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
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
Precertification required and absent.