CLM-2026-022254
Canyon Cardiovascular Associates, Cardiology. Service 2026-01-22 at outpatient hospital (POS 22). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Mason Smith
- Member ID
- UHC-13514-35
- Date of birth
- 1961-02-15
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-426080
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9339
- Coverage period
- 2021-03-01 to present
- Deductible
- $401.07 of $500.0080%
- Out-of-pocket maximum
- $190.52 of $1,500.0013%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9875837467
- Network
- In network
- Rendering NPI
- 5002155203
- Location
- Phoenix, AZ · TIN 87-2997338
- 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 | $1,167.00 | $641.85 | — | — | Review |
| Totals | $1,167.00 | $641.85 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-113888
- 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-007303 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-22: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 20 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 | Pass | In-network provider Canyon Cardiovascular Associates (9875837467). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with atherosclerotic heart disease of native coronary artery ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Cardiovascular Associates2026-01-22 11:02
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-11 05:33
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-113888.pdf8 pages
Itemised statement totalling $1167.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with atherosclerotic heart disease of native coronary artery ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004501 | 2026-03-21 | Cornerstone Clinical Laboratories | $79.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.