CLM-2026-000903
Canyon Primary Care Associates, Family Medicine. Service 2025-09-07 at office (POS 11). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Alan Lane
- Member ID
- UHC-36065-99
- Date of birth
- 1982-06-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-417112
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5703
- Coverage period
- 2023-08-01 to present
- Deductible
- $215.86 of $2,500.009%
- Out-of-pocket maximum
- $3,145.18 of $7,500.0042%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4536468513
- Network
- In network
- Rendering NPI
- 7181382533
- Location
- Dallas, TX · TIN 25-8447887
- 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 | $19.00 | $11.78 | — | — | DeniedCO29 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $199.00 | $123.38 | — | — | DeniedCO29 |
| Totals | $218.00 | $135.16 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-281226
- 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-014824 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-07: MEDICARE-ADV-B (MA), effective 2023-08-01. | |
| Timely filing | Fail | CO29 | Received 167 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 | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Primary Care Associates (4536468513). | |
| 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 Associates2025-09-07 17:31
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-21 01:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 167 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022545 | 2026-09-05 | Pinecrest Regional Medical Center | $2,474.00 | Approved |
| CLM-2026-018285 | 2026-04-23 | Mesa GI Associates | $218.00 | 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
Received after the timely-filing limit.