CLM-2026-004352
Canyon Heart Institute, Cardiology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Albert Castro
- Member ID
- UHC-91693-71
- Date of birth
- 1982-05-10
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-401459
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6332
- Coverage period
- 2025-02-01 to present
- Deductible
- $823.35 of $1,500.0055%
- Out-of-pocket maximum
- $1,336.58 of $6,000.0022%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 5561054656
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,699.00 | $3,014.55 | — | — | DeniedCO197 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,168.00 | $525.60 | — | — | DeniedCO197 |
| Totals | $7,867.00 | $3,540.15 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-292176
- 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-004012 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-05: MEDICARE-ADV-A (MA), effective 2025-02-01. | |
| Timely filing | Pass | Received 17 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 Heart Institute2026-09-05 16:52
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-22 04:17
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-292176.pdf6 pages
Itemised statement totalling $7867.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027890 | 2026-05-26 | Mesa Regional Medical Center | $1,324.00 | Needs review |
| CLM-2026-027889 | 2026-05-26 | Heritage Community Hospital | $1,324.00 | Approved |
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.