CLM-2026-024183
Canyon Cardiovascular Associates, Cardiology. Service 2026-04-19 at office (POS 11). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Rebecca Clark
- Member ID
- UHC-91106-06
- Date of birth
- 2004-07-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-402214
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0124
- Coverage period
- 2022-09-01 to present
- Deductible
- $309.56 of $500.0062%
- Out-of-pocket maximum
- $497.13 of $1,000.0050%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 4653465672
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- none / none
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 | $253.00 | $113.85 | — | — | DeniedCO204 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 2 | $396.00 | $178.20 | — | — | DeniedCO204 |
| Totals | $649.00 | $292.05 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-271043
- 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-000383 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-19: SELECT-EPO (EPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 38 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 EPO 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 Associates2026-04-19 12:30
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-27 06:50
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)2026-05-27 14:04
Escalated to nurse reviewer for clinical opinion.
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 EPO 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.