CLM-2026-016963
Canyon Cardiovascular Associates, Cardiology. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Gregory Lopez
- Member ID
- UHC-68258-65
- Date of birth
- 2003-10-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413871
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1911
- Coverage period
- 2021-01-01 to present
- Deductible
- $824.86 of $3,500.0024%
- Out-of-pocket maximum
- $4,166.93 of $10,500.0040%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 9297782903
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- PA2026267712 / REF715832
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 | $590.00 | $265.50 | — | — | DeniedCO204 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | 25 | 1 | 1,2 | $5,643.00 | $2,539.35 | — | — | DeniedCO204 |
| Totals | $6,233.00 | $2,804.85 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-987495
- 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-001443 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-29: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026267712 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 4930621931 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2025-12-29 11:09
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-05 02:27
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026267712_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2025-12-29 to 2026-03-29.
- Itemized billitemized_PA-987495.pdf8 pages
Itemised statement totalling $6233.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 4930621931 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.