Claims workbench/CLM-2026-000539
Institutional claim · UB-04 · EDI 837I

CLM-2026-000539

Canyon Cardiovascular Associates, Cardiology. Service 2026-06-27 at outpatient hospital (POS 22). Received 2026-08-06.

Pended
Billed
$1,820.00
2 lines
Allowed
$1,001.00
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
CO16, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Canyon Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI
5033795498
Network
In network
Rendering NPI
7908029920
Location
Austin, TX · TIN 36-3628550
Authorisation / referral
none / REF557750

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193306
rev 0480
Echocardiogram, complete—11$1,166.00$641.30——PendedCO16
293015Cardiovascular stress test—11$654.00$359.70——PendedCO16
Totals$1,820.00$1,001.00——
Diagnoses (ICD-10-CM)
  • 1. I48.91 Unspecified atrial fibrillationprincipal
  • 2. I10 Essential (primary) hypertension
  • 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
Claim header
Patient account
PA-210354
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 40 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Canyon Cardiovascular Associates (5033795498).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Canyon Cardiovascular Associates2026-06-27 12:25

    Patient seen for unspecified atrial fibrillation.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-210354.pdf3 pages

    Itemised statement totalling $1820.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity. Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue