CLM-2026-017938
Canyon Cardiovascular Associates, Cardiology. Service 2026-08-10 at office (POS 11). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Ralph Graham
- Member ID
- UHC-10242-73
- Date of birth
- 1981-01-27
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408378
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8922
- Coverage period
- 2022-03-01 to present
- Deductible
- $199.34 of $3,500.006%
- Out-of-pocket maximum
- $307.07 of $7,000.004%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 5091826862
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- none / REF240486
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $278.00 | $125.10 | — | — | DeniedCO204 |
| Totals | $278.00 | $125.10 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-229581
- 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-000817 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-10: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 3 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 | 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 Associates2026-08-10 09:51
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-08-13 03:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-13 17:14
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000804 | 2025-12-09 | Unity Medical Group | $260.00 | Needs review |
| CLM-2026-024655 | 2025-11-20 | Evergreen Clinical Laboratories | $92.00 | Approved |
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.