CLM-2026-000493
Canyon Heart Institute, Cardiology. Service 2026-09-28 at outpatient hospital (POS 22). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Beverly Hughes
- Member ID
- UHC-84048-28
- Date of birth
- 1988-06-28
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-405733
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8923
- Coverage period
- 2022-06-01 to present
- Deductible
- $195.14 of $1,000.0020%
- Out-of-pocket maximum
- $639.04 of $2,000.0032%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 5481490865
- Location
- Nashville, TN · TIN 19-4178829
- 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 | $392.00 | $176.40 | $176.40 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1,2 | $1,209.00 | $544.05 | $544.05 | $0.00 | Paid |
| Totals | $1,601.00 | $720.45 | $720.45 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-881092
- 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-039856 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-28: CHOICE-PLUS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 6 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Canyon Heart Institute2026-09-28 17:55
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-881092.pdf5 pages
Itemised statement totalling $1601.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016203 | 2026-04-11 | Summit Clinical Laboratories | $135.00 | Denied |
| CLM-2026-003381 | 2026-08-02 | Canyon Medical Group | $302.00 | 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.