CLM-2026-013014
Canyon Cardiovascular Associates, Cardiology. Service 2026-02-25 at outpatient hospital (POS 22). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Roger Robertson
- Member ID
- UHC-90440-20
- Date of birth
- 1977-02-25
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-411098
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0452
- Coverage period
- 2021-04-01 to present
- Deductible
- $690.27 of $1,000.0069%
- Out-of-pocket maximum
- $1,734.91 of $4,000.0043%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 8379746422
- Location
- Tampa, FL · TIN 34-8825737
- 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 | $929.00 | $418.05 | $342.23 | $75.82 | Paid |
| Totals | $929.00 | $418.05 | $342.23 | $75.82 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-234219
- 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-017483 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-25: - (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 7 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 Cardiovascular Associates2026-02-25 15:47
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-234219.pdf4 pages
Itemised statement totalling $929.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005937 | 2026-08-02 | Summit Counseling Center | $293.00 | 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.