CLM-2026-032045
Canyon Cardiovascular Associates, Cardiology. Service 2026-07-18 at outpatient hospital (POS 22). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Debra Cox
- Member ID
- UHC-62132-15
- Date of birth
- 1993-06-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-419409
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3717
- Coverage period
- 2022-10-01 to present
- Deductible
- $16.84 of $1,000.002%
- Out-of-pocket maximum
- $469.79 of $2,000.0023%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4930621931
- Network
- Out of network
- Rendering NPI
- 4118294840
- Location
- Tampa, FL · TIN 34-8825737
- Authorisation / referral
- none / REF459009
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 | $1,506.00 | $677.70 | — | — | DeniedCO204 |
| Totals | $1,506.00 | $677.70 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-207691
- 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-019798 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-18: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 3 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 Associates2026-07-18 17:27
Patient seen for heart failure, unspecified.
- SystemSystem: Claims system2026-07-21 03:24
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-207691.pdf5 pages
Itemised statement totalling $1506.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027968 | 2026-04-13 | Meadow GI Associates | $256.00 | Denied |
| CLM-2026-006255 | 2026-03-13 | Cornerstone Bone and Joint Center | $10,312.00 | Approved |
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.