CLM-2026-013282
Canyon Cardiovascular Associates, Cardiology. Service 2026-09-20 at office (POS 11). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Mason Porter
- Member ID
- UHC-76399-31
- Date of birth
- 1984-11-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-401270
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3986
- Coverage period
- 2022-07-01 to present
- Deductible
- $2,812.22 of $3,500.0080%
- Out-of-pocket maximum
- $530.57 of $14,000.004%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 3671550705
- Location
- Austin, TX · TIN 36-3628550
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | 59 | 1 | 1 | $428.00 | $265.36 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $312.00 | $193.44 | — | — | Review |
| Totals | $740.00 | $458.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-395598
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001447 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-20: N/A (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 25 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 (5033795498). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2026-09-20 11:18
Patient seen for essential (primary) hypertension. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-10-15 00:15
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-15 15:34
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-395598.pdf13 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033128 | 2026-03-19 | Evergreen Counseling Center | $199.00 | Approved |
| CLM-2026-005745 | 2026-04-01 | Northgate Reference Lab | $133.00 | Approved |
| CLM-2026-002318 | 2026-02-24 | Mesa Family Practice | $223.00 | Approved |
| CLM-2026-031756 | 2025-12-30 | Lakeside Internal Medicine Associates | $94.00 | Approved |
| CLM-2026-025796 | 2025-12-06 | Evergreen Diagnostic Imaging | $2,054.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.