CLM-2026-013331
Canyon Cardiovascular Associates, Cardiology. Service 2026-03-10 at outpatient hospital (POS 22). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Ashley Morrison
- Member ID
- UHC-68018-38
- Date of birth
- 1987-09-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405056
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8099
- Coverage period
- 2023-01-01 to 2026-06-24
- Deductible
- $408.30 of $500.0082%
- Out-of-pocket maximum
- $343.56 of $2,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 8096065825
- Location
- Austin, TX · TIN 36-3628550
- 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 | $916.00 | $503.80 | — | — | DeniedCO29 |
| Totals | $916.00 | $503.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-922879
- 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-037059 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: SELECT-EPO (EPO), effective 2023-01-01, terms 2026-06-24. | |
| Timely filing | Fail | CO29 | Received 114 days after the last date of service (limit 90). Time limit for filing has expired |
| 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) | 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 12:31
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-07-02 04:22
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-02 10:19
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-922879.pdf8 pages
Itemised statement totalling $916.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 114 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009755 | 2026-08-02 | Northgate Reference Lab | $77.00 | 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
Received after the timely-filing limit.