Claims workbench/CLM-2026-030045
Institutional claim · UB-04 · EDI 837I

CLM-2026-030045

Canyon Cardiovascular Associates, Cardiology. Service 2026-07-22 at outpatient hospital (POS 22). Received 2026-08-07.

Denied
Billed
$7,107.00
2 lines
Allowed
$3,908.85
if approved
Plan pays
—
Denied
Member owes
—
no coverage
Rules engine
Deny
CO197
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Sofia Duncan
Member ID
none on golden record
Date of birth
1938-06-28
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-405848
Relationship
Self, Denver, CO

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Canyon Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI
9875837467
Network
In network
Rendering NPI
2745425431
Location
Phoenix, AZ · TIN 87-2997338
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193458
rev 0481
Cardiac catheterisation, left heart—11$5,975.00$3,286.25——DeniedCO197
293306
rev 0480
Echocardiogram, complete2511$1,132.00$622.60——DeniedCO197
Totals$7,107.00$3,908.85——
Diagnoses (ICD-10-CM)
  • 1. I50.9 Heart failure, unspecifiedprincipal
Claim header
Patient account
PA-144623
Frequency code
1 (original)
Accident
No
DRG
287
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-040904 (verified, link confidence 0.97).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationFailCO19793458 require precertification; no authorisation number on the claim.
Precertification or authorization absent
Provider networkPassIn-network provider Canyon Cardiovascular Associates (9875837467).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Canyon Cardiovascular Associates2026-07-22 16:39

    Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-08-07 04:01

    Procedure requires precertification; no authorisation number on the claim and none found in the UM system.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-144623.pdf3 pages

    Itemised statement totalling $7107.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim. Prior authorisation: 93458 require precertification; no authorisation number on the claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO197scenario: No auth

Precertification required and absent.

Review queueMember identity