CLM-2026-026794
Canyon Cardiovascular Associates, Cardiology. Service 2026-05-09 at outpatient hospital (POS 22). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Benjamin Fuller
- Member ID
- UHC-02333-75
- Date of birth
- 1980-12-22
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-422902
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group UNKNOWN
- Coverage period
- 2022-10-01 to present
- Deductible
- $922.71 of $1,500.0062%
- Out-of-pocket maximum
- $600.39 of $3,000.0020%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 1703656458
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- none / REF142959
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 | $1,171.00 | $526.95 | — | — | DeniedCO204 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $662.00 | $297.90 | — | — | DeniedCO204 |
| Totals | $1,833.00 | $824.85 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-299596
- 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-003934 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-09: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 45 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 Associates2026-05-09 12:24
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-23 01:59
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-23 12:09
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-299596.pdf3 pages
Itemised statement totalling $1833.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider 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
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.