CLM-2026-019239
Canyon Cardiovascular Associates, Cardiology. Service 2026-05-01 at outpatient hospital (POS 22). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Kelly Guzzman
- Member ID
- UHC-32090-31
- Date of birth
- 1953-06-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427298
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3742
- Coverage period
- 2024-03-01 to present
- Deductible
- $251.50 of $3,500.007%
- Out-of-pocket maximum
- $834.71 of $7,000.0012%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 7540664720
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- PA2025390911 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,440.00 | $2,448.00 | $2,448.00 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 2 | $638.00 | $287.10 | $287.10 | $0.00 | Paid |
| Totals | $6,078.00 | $2,735.10 | $2,735.10 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-771704
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-032408 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-01: OPTIONS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025390911 on file for 93458. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-05-01 16:39
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Prior auth letterPA2025390911_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-01 to 2026-07-30.
- Itemized billitemized_PA-771704.pdf2 pages
Itemised statement totalling $6078.00 across 2 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.