CLM-2026-015362
Canyon Cardiovascular Associates, Cardiology. Service 2026-01-09 at outpatient hospital (POS 22). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Brandon Carpenter
- Member ID
- UHC-41042-30
- Date of birth
- 1975-06-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-417725
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8981
- Coverage period
- 2025-11-01 to present
- Deductible
- $412.12 of $500.0082%
- Out-of-pocket maximum
- $695.78 of $1,500.0046%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 4842236166
- Location
- Austin, TX · TIN 36-3628550
- Authorisation / referral
- PA2025313879 / 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 | $1,174.00 | $645.70 | $255.23 | $390.47 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $682.00 | $375.10 | $112.53 | $262.57 | Paid |
| 3 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,093.00 | $2,801.15 | $840.35 | $1,960.80 | Paid |
| Totals | $6,949.00 | $3,821.95 | $1,208.11 | $2,613.84 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-783457
- 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-012701 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-09: NULL (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025313879 on file for 93458. | |
| 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 Associates2026-01-09 09:40
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025313879_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-01-09 to 2026-04-09.
- Itemized billitemized_PA-783457.pdf2 pages
Itemised statement totalling $6949.00 across 3 lines.
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
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.