CLM-2026-004542
Canyon Cardiovascular Associates, Cardiology. Service 2026-03-15 at outpatient hospital (POS 22). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Robert Hill
- Member ID
- UHC-09753-41
- Date of birth
- 2000-11-17
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-425958
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5716
- Coverage period
- 2023-04-01 to present
- Deductible
- $279.76 of $500.0056%
- Out-of-pocket maximum
- $247.03 of $1,500.0016%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 1508654310
- Location
- Austin, TX · TIN 36-3628550
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,382.00 | $760.10 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,178.00 | $3,397.90 | — | — | DeniedCO197 |
| Totals | $7,560.00 | $4,158.00 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-333634
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023636 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-15: MEDICARE-ADV-B (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 18 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 | Pass | In-network provider Canyon Cardiovascular Associates (5033795498). | |
| 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 Associates2026-03-15 12:16
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-02 05:51
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-02 15:11
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-333634.pdf6 pages
Itemised statement totalling $7560.00 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.
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.