CLM-2026-005322
Canyon Cardiovascular Associates, Cardiology. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Vincent Thomas
- Member ID
- UHC-72529-98
- Date of birth
- 1939-06-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418147
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5745
- Coverage period
- 2023-03-01 to present
- Deductible
- $423.09 of $3,500.0012%
- Out-of-pocket maximum
- $2,980.53 of $10,500.0028%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 3246644991
- Location
- Austin, TX · TIN 36-3628550
- Authorisation / referral
- PA2025711425 / 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 | $1,017.00 | $559.35 | $559.35 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | 25 | 1 | 1 | $8,525.00 | $4,688.75 | $3,168.92 | $1,519.83 | Paid |
| 3 | 93015 | Cardiovascular stress test | 25 | 1 | 1 | $532.00 | $292.60 | $87.78 | $204.82 | Paid |
| Totals | $10,074.00 | $5,540.70 | $3,816.05 | $1,724.65 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-667563
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008558 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-17: SELECT-EPO (EPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025711425 on file for 93458. | |
| 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 Associates2026-08-17 11:55
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025711425_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-08-17 to 2026-11-15.
- Itemized billitemized_PA-667563.pdf3 pages
Itemised statement totalling $10074.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034423 | 2026-06-07 | Heritage GI Associates | $298.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.