CLM-2026-032230
Canyon Cardiovascular Associates, Cardiology. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- David Larson
- Member ID
- UHC-94457-68
- Date of birth
- 1986-04-27
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-418385
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8907
- Coverage period
- 2021-11-01 to present
- Deductible
- $838.75 of $3,500.0024%
- Out-of-pocket maximum
- $1,459.91 of $7,000.0021%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 9875837467
- Network
- In network
- Rendering NPI
- 5300934325
- Location
- Phoenix, AZ · TIN 87-2997338
- Authorisation / referral
- PA2026505564 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,180.00 | $3,949.00 | — | — | DeniedCO29 |
| Totals | $7,180.00 | $3,949.00 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-182796
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-030109 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-07: MEDICARE-ADV-B (MA), effective 2021-11-01. | |
| Timely filing | Fail | CO29 | Received 119 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 | Authorisation PA2026505564 on file for 93458. | |
| Provider network | Pass | In-network provider Canyon Cardiovascular Associates (9875837467). | |
| 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 Associates2026-04-07 13:00
Patient seen for heart failure, unspecified.
- SystemSystem: Claims system2026-08-04 01:44
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-04 12:42
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026505564_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-04-07 to 2026-07-06.
- Itemized billitemized_PA-182796.pdf9 pages
Itemised statement totalling $7180.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 119 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.