CLM-2026-000933
Canyon Cardiovascular Associates, Cardiology. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Eric Hall
- Member ID
- UHC-73484-68
- Date of birth
- 1956-12-06
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-422049
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9147
- Coverage period
- 2024-09-01 to present
- Deductible
- $672.05 of $1,000.0067%
- Out-of-pocket maximum
- $557.98 of $2,000.0028%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 4316394467
- Location
- Tampa, FL · TIN 34-8825737
- 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 | $6,694.00 | $3,012.30 | — | — | DeniedCO197 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $552.00 | $248.40 | — | — | DeniedCO197 |
| Totals | $7,246.00 | $3,260.70 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-392091
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022895 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-B (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 45 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 | 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 Cardiovascular Associates2026-02-13 18:06
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-30 03:33
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-30 15:10
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-392091.pdf5 pages
Itemised statement totalling $7246.00 across 2 lines.
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. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.