CLM-2026-010764
Canyon Cardiovascular Associates, Cardiology. Service 2026-03-10 at outpatient hospital (POS 22). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Aisha Simmons
- Member ID
- UHC-46654-44
- Date of birth
- 1944-04-21
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-402341
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9597
- Coverage period
- 2021-11-01 to present
- Deductible
- $221.18 of $500.0044%
- Out-of-pocket maximum
- $713.28 of $2,000.0036%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9875837467
- Network
- In network
- Rendering NPI
- 1420671343
- Location
- Phoenix, AZ · TIN 87-2997338
- Authorisation / referral
- none / REF149935
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 | $410.00 | $225.50 | $225.50 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,513.00 | $832.15 | $131.20 | $700.95 | Paid |
| Totals | $1,923.00 | $1,057.65 | $356.70 | $700.95 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-228217
- 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-006954 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| 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 (9875837467). | |
| 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 Associates2026-03-10 17:29
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-228217.pdf9 pages
Itemised statement totalling $1923.00 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-2026-013302 | 2026-09-23 | Evergreen Reference Lab | $193.00 | Approved |
| CLM-2026-033848 | 2026-07-06 | Meadow Physical Therapy | $152.00 | Denied |
| CLM-2026-002277 | 2026-07-29 | Riverside Community Hospital | $1,723.00 | Approved |
| CLM-2026-019749 | 2026-04-22 | Lakeside Bone and Joint Center | $195.00 | 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.