CLM-2026-004185
Canyon Heart Institute, Cardiology. Service 2026-05-29 at outpatient hospital (POS 22). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Raymond Salazar
- Member ID
- UHC-57532-56
- Date of birth
- 1996-10-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-403232
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6978
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,180.71 of $1,500.0079%
- Out-of-pocket maximum
- $632.00 of $6,000.0011%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 9355370286
- Location
- Nashville, TN · TIN 19-4178829
- Authorisation / referral
- PA2025028740 / REF168372
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 | $9,015.00 | $4,056.75 | — | — | DeniedCO204 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $374.00 | $168.30 | — | — | DeniedCO204 |
| Totals | $9,389.00 | $4,225.05 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-663054
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015771 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-29: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025028740 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 3505415729 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 Heart Institute2026-05-29 13:21
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-12 01:29
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025028740_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-29 to 2026-08-27.
- Itemized billitemized_PA-663054.pdf5 pages
Itemised statement totalling $9389.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3505415729 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023885 | 2026-02-13 | Lakeside Behavioral Health | $264.00 | Denied |
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
No out-of-network benefit on this plan.