CLM-2026-028830
Canyon Heart Institute, Cardiology. Service 2026-09-12 at outpatient hospital (POS 22). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Dennis Morgan
- Member ID
- UHC-75155-83
- Date of birth
- 1955-03-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429380
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3982
- Coverage period
- 2023-01-01 to present
- Deductible
- $436.02 of $500.0087%
- Out-of-pocket maximum
- $58.78 of $2,000.003%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 7254496582
- Location
- Nashville, TN · TIN 19-4178829
- Authorisation / referral
- PA2026328381 / REF907780
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 | $978.00 | $440.10 | — | — | DeniedCO204 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,434.00 | $2,445.30 | — | — | DeniedCO204 |
| Totals | $6,412.00 | $2,885.40 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-982602
- 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-045186 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-12: NAVIGATE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026328381 on file for 93458. | |
| Provider network | Fail | CO204 | Billing provider 3505415729 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 Heart Institute2026-09-12 13:39
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-27 06:01
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-27 10:51
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026328381_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-09-12 to 2026-12-11.
- Itemized billitemized_PA-982602.pdf9 pages
Itemised statement totalling $6412.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3505415729 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.