CLM-2026-026651
Canyon Cardiovascular Associates, Cardiology. Service 2026-05-02 at office (POS 11). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Nathan Robertson
- Member ID
- UHC-93478-47
- Date of birth
- 1997-07-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419590
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group NULL
- Coverage period
- 2023-03-01 to present
- Deductible
- $428.68 of $1,500.0029%
- Out-of-pocket maximum
- $357.97 of $3,000.0012%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9875837467
- Network
- In network
- Rendering NPI
- 4460885542
- Location
- Phoenix, AZ · TIN 87-2997338
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $338.00 | $209.56 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $266.00 | $164.92 | — | — | Review |
| Totals | $604.00 | $374.48 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-691285
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-013711 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: UNKNOWN (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 18 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: “Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan”. 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 Associates2026-05-02 10:11
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-20 01:34
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-20 10:53
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028038 | 2026-03-21 | Pinecrest GI Associates | $4,166.00 | 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.