CLM-2026-006549
Canyon Cardiovascular Associates, Cardiology. Service 2026-03-24 at outpatient hospital (POS 22). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Aisha Larson
- Member ID
- UHC-69901-39
- Date of birth
- 1949-09-22
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-429221
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1530
- Coverage period
- 2024-05-01 to 2026-08-02
- Deductible
- $1,290.67 of $2,500.0052%
- Out-of-pocket maximum
- $2,222.91 of $10,000.0022%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 5915072503
- Location
- Tampa, FL · TIN 34-8825737
- 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 | $535.00 | $240.75 | $240.75 | $0.00 | Paid |
| Totals | $535.00 | $240.75 | $240.75 | $0.00 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-642678
- 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-024306 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-24: - (PPO), effective 2024-05-01, terms 2026-08-02. | |
| Timely filing | Pass | Received 13 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 | 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 Cardiovascular Associates2026-03-24 12:00
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-642678.pdf8 pages
Itemised statement totalling $535.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider 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-2026-032788 | 2026-07-23 | Northgate Counseling Center | $233.00 | Approved |
| CLM-2026-021245 | 2026-08-19 | Unity Community Hospital | $3,791.00 | Denied |
| CLM-2026-031940 | 2026-08-12 | Summit Regional Medical Center | $2,309.00 | Denied |
| CLM-2026-000469 | 2026-08-09 | Unity Medical Group | $220.00 | Denied |
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.