CLM-2026-010288
Canyon Cardiovascular Associates, Cardiology. Service 2026-02-04 at outpatient hospital (POS 22). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Arjun Scott
- Member ID
- UHC-41301-41
- Date of birth
- 1999-05-04
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-423304
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9373
- Coverage period
- 2024-06-01 to 2026-07-28
- Deductible
- $1,683.56 of $3,500.0048%
- Out-of-pocket maximum
- $1,112.70 of $7,000.0016%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 3853750677
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- none / REF490381
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 | $647.00 | $291.15 | — | — | DeniedCO204 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,466.00 | $659.70 | — | — | DeniedCO204 |
| Totals | $2,113.00 | $950.85 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-971036
- 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-013677 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-04: CORE-HMO (HMO), effective 2024-06-01, terms 2026-07-28. | |
| 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 | Fail | CO204 | Billing provider 4930621931 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-02-04 18:31
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-02-17 06:58
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-971036.pdf4 pages
Itemised statement totalling $2113.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 4930621931 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027772 | 2026-03-06 | Canyon Counseling Center | $419.00 | Denied |
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
No out-of-network benefit on this plan.