CLM-2026-027367
Canyon Heart Institute, Cardiology. Service 2025-12-25 at outpatient hospital (POS 22). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Nancy Silva
- Member ID
- UHC-91783-24
- Date of birth
- 1938-11-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404253
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5322
- Coverage period
- 2022-06-01 to present
- Deductible
- $369.44 of $500.0074%
- Out-of-pocket maximum
- $41.35 of $1,000.004%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 2325245415
- Location
- Nashville, TN · TIN 19-4178829
- 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 | $1,079.00 | $485.55 | $237.06 | $248.49 | Paid |
| Totals | $1,079.00 | $485.55 | $237.06 | $248.49 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-518906
- 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-006044 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: MEDICARE-ADV-A (MA), effective 2022-06-01. | |
| Timely filing | Pass | Received 26 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 | 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 Heart Institute2025-12-25 09:35
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-518906.pdf6 pages
Itemised statement totalling $1079.00 across 1 line.
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.