CLM-2026-033335
Canyon Heart Institute, Cardiology. Service 2026-03-24 at office (POS 11). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Jerry Romero
- Member ID
- UHC-98312-99
- Date of birth
- 1964-03-24
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-412844
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5539
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,569.72 of $3,500.0073%
- Out-of-pocket maximum
- $3,838.54 of $10,500.0037%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 3505415729
- Network
- Out of network
- Rendering NPI
- 5266569354
- Location
- Nashville, TN · TIN 19-4178829
- Authorisation / referral
- none / REF333698
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $317.00 | $142.65 | — | — | DeniedCO204 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $386.00 | $173.70 | — | — | DeniedCO204 |
| Totals | $703.00 | $316.35 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-281837
- 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-023099 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-24: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 6 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 3505415729 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 Heart Institute2026-03-24 17:42
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-30 03:15
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
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3505415729 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-2026-016075 | 2026-06-03 | Evergreen Orthopedic Specialists | $5,950.00 | Approved |
| CLM-2026-013531 | 2026-06-03 | Desert Regional Medical Center | $951.00 | Needs review |
| CLM-2026-017055 | 2026-02-27 | Canyon Reference Lab | $141.00 | Needs review |
| CLM-2026-017054 | 2026-02-27 | Canyon Reference Lab | $141.00 | Approved |
| CLM-2026-002754 | 2025-10-06 | Canyon Reference Lab | $167.00 | Denied |
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.