CLM-2026-006805
Canyon Heart Institute, Cardiology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- William Daniesl
- Member ID
- UHC-94662-39
- Date of birth
- 1969-09-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414893
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6232
- Coverage period
- 2025-07-01 to present
- Deductible
- $430.10 of $500.0086%
- Out-of-pocket maximum
- $916.17 of $2,000.0046%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 2192907220
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,557.00 | $700.65 | $132.97 | $567.68 | Paid |
| Totals | $1,557.00 | $700.65 | $132.97 | $567.68 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-777559
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003444 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: MEDICARE-ADV-A (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 12 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 Heart Institute2025-12-30 17:22
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-777559.pdf6 pages
Itemised statement totalling $1557.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.