CLM-2026-029426
Canyon Cardiovascular Associates, Cardiology. Service 2025-12-14 at office (POS 11). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Omar Rios
- Member ID
- UHC-84757-69
- Date of birth
- 1949-12-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415496
- Relationship
- Child
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6951
- Coverage period
- 2021-09-01 to present
- Deductible
- $308.86 of $1,500.0021%
- Out-of-pocket maximum
- $1,698.55 of $4,500.0038%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 9292739213
- Location
- Austin, TX · TIN 36-3628550
- 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 | $468.00 | $290.16 | — | — | DeniedCO29 |
| Totals | $468.00 | $290.16 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-207384
- 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-035229 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-14: MEDICARE-ADV-A (MA), effective 2021-09-01. | |
| Timely filing | Fail | CO29 | Received 185 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (5033795498). | |
| 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 Associates2025-12-14 10:18
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-17 01:41
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 185 days after the last date of service (limit 90).
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
Received after the timely-filing limit.