CLM-2026-011136
Canyon Cardiovascular Associates, Cardiology. Service 2026-04-09 at outpatient hospital (POS 22). Received 2026-05-11.
Member
Resolved through the identity graph
- Member
- William Kim
- Member ID
- UHC-42424-16
- Date of birth
- 2003-05-19
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421500
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2025-08-01 to present
- Deductible
- $754.35 of $1,000.0075%
- Out-of-pocket maximum
- $527.20 of $2,000.0026%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9875837467
- Network
- In network
- Rendering NPI
- 5949076835
- Location
- Phoenix, AZ · TIN 87-2997338
- 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 | $630.00 | $346.50 | $265.82 | $80.68 | Paid |
| Totals | $630.00 | $346.50 | $265.82 | $80.68 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-850078
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026527 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-09: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 32 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 Associates2026-04-09 13:52
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-850078.pdf7 pages
Itemised statement totalling $630.00 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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014880 | 2026-07-07 | Summit Counseling Center | $3,065.00 | Needs review |
| CLM-2026-012114 | 2026-03-16 | Lakeside Bone and Joint Center | $8,486.00 | 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.