CLM-2026-003427
Canyon Cardiovascular Associates, Cardiology. Service 2025-07-01 at office (POS 11). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Juan Wheeler
- Member ID
- UHC-16090-07
- Date of birth
- 1984-09-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402684
- Relationship
- Child, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3189
- Coverage period
- 2023-03-01 to present
- Deductible
- $804.90 of $2,500.0032%
- Out-of-pocket maximum
- $622.45 of $10,000.006%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 6804079898
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- none / REF123213
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $300.00 | $135.00 | — | — | DeniedCO29 |
| Totals | $300.00 | $135.00 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-223306
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005233 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-07-01: NAVIGATE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Fail | CO29 | Received 200 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 4930621931 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2025-07-01 11:37
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-17 04:24
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 200 days after the last date of service (limit 90). Provider network: Billing provider 4930621931 is out of network and the HMO plan has no out-of-network benefit.
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
Received after the timely-filing limit.