CLM-2026-000621
Canyon Primary Care Associates, Family Medicine. Service 2026-03-13 at office (POS 11). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Rachel Munoz
- Member ID
- UHC-15937-04
- Date of birth
- 2004-03-17
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407418
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5816
- Coverage period
- 2022-04-01 to present
- Deductible
- $1,147.31 of $1,500.0076%
- Out-of-pocket maximum
- $2,128.91 of $4,500.0047%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2780458347
- Network
- In network
- Rendering NPI
- 1925992764
- Location
- Miami, FL · TIN 49-9122267
- Authorisation / referral
- none / none
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 | 36415 | Venipuncture | — | 1 | 1 | $20.00 | $12.40 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $204.00 | $126.48 | — | — | DeniedCO18 |
| Totals | $224.00 | $138.88 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-483396
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009939 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-13: CHOICE-PLUS-PPO (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-000620: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Primary Care Associates (2780458347). | |
| 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 Primary Care Associates2026-03-13 12:14
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-04-26 03:48
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-000620: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032148 | 2026-05-22 | Meadow GI Associates | $302.00 | Approved |
| CLM-2026-003540 | 2026-04-28 | Sunrise Medical Group | $352.00 | Approved |
| CLM-2026-000620 | 2026-03-13 | Canyon Primary Care Associates | $224.00 | Approved |
| CLM-2026-021552 | 2025-12-30 | Canyon Medical Group | $388.00 | 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
Exact duplicate of an earlier submission.