CLM-2026-009206
Canyon Cardiovascular Associates, Cardiology. Service 2026-10-06 at outpatient hospital (POS 22). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Samantha Morris
- Member ID
- UHC-72872-02
- Date of birth
- 2004-09-22
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-426228
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6780
- Coverage period
- 2021-04-01 to present
- Deductible
- $1,565.58 of $3,500.0045%
- Out-of-pocket maximum
- $6,991.53 of $14,000.0050%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 6461874805
- Location
- Austin, TX · TIN 36-3628550
- Authorisation / referral
- PA2026333853 / 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 | $1,459.00 | $802.45 | $802.45 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,440.00 | $4,642.00 | $2,184.98 | $2,457.02 | Paid |
| Totals | $9,899.00 | $5,444.45 | $2,987.43 | $2,457.02 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-799896
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019686 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-10-06: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026333853 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 Associates2026-10-06 16:24
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026333853_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-10-06 to 2027-01-04.
- Itemized billitemized_PA-799896.pdf2 pages
Itemised statement totalling $9899.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009207 | 2026-10-06 | Northgate Heart Institute | $9,899.00 | Needs review |
| CLM-2026-019433 | 2026-06-19 | Unity Primary Care Associates | $203.00 | Approved |
| CLM-2026-014093 | 2026-02-03 | Riverside Internal Medicine Associates | $158.00 | 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.