CLM-2026-005394
Canyon Cardiovascular Associates, Cardiology. Service 2026-08-05 at outpatient hospital (POS 22). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Carlos Williamson
- Member ID
- UHC-61358-72
- Date of birth
- 1977-07-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422610
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9366
- Coverage period
- 2025-10-01 to 2026-07-12
- Deductible
- $1,038.23 of $3,500.0030%
- Out-of-pocket maximum
- $3,115.09 of $14,000.0022%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 8235654323
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $596.00 | $327.80 | — | — | DeniedCO27 |
| Totals | $596.00 | $327.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-883417
- 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-001429 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-05 is after coverage terminated on 2026-07-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-08-05 10:41
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-08 00:31
Attachments
Documents received with the claim
- Itemized billitemized_PA-883417.pdf7 pages
Itemised statement totalling $596.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-05 is after coverage terminated on 2026-07-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004188 | 2026-03-21 | Lakeside Medical Group | $195.00 | Approved |
| CLM-2026-012104 | 2026-01-02 | Summit Clinical Laboratories | $102.00 | Approved |
| CLM-2026-014061 | 2025-12-28 | Riverside Primary Care Associates | $500.00 | 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
Service after coverage termination.