CLM-2026-032239
Canyon Cardiovascular Associates, Cardiology. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Omar Ferguson
- Member ID
- UHC-22742-24
- Date of birth
- 1950-11-04
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424108
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3486
- Coverage period
- 2022-07-01 to present
- Deductible
- $678.05 of $1,000.0068%
- Out-of-pocket maximum
- $878.36 of $2,000.0044%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5033795498
- Network
- In network
- Rendering NPI
- 4655512729
- Location
- Austin, TX · TIN 36-3628550
- Authorisation / referral
- none / 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,280.00 | $704.00 | $436.57 | $267.43 | Paid |
| Totals | $1,280.00 | $704.00 | $436.57 | $267.43 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-718902
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010293 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-17: MEDICARE-ADV-B (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 38 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 | 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 Associates2026-08-17 10:00
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-718902.pdf2 pages
Itemised statement totalling $1280.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026113 | 2026-06-06 | Harbor Physical Therapy | $342.00 | Approved |
| CLM-2026-004213 | 2026-03-25 | Sunrise Physical Therapy | $300.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.