Professional claim · CMS-1500 · EDI 837P
CLM-2026-001063
Canyon Medical Group, Internal Medicine. Service 2026-08-28 at office (POS 11). Received 2026-09-27.
Approved
Billed
$265.00
2 lines
Allowed
$164.30
contract rate applied
Plan pays
$134.30
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Arjun Cruz
- Member ID
- UHC-83745-64
- Date of birth
- 1941-01-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412156
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3790
- Coverage period
- 2021-03-01 to present
- Deductible
- $963.37 of $1,500.0064%
- Out-of-pocket maximum
- $2,175.17 of $6,000.0036%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 7923867437
- Location
- Houston, TX · TIN 52-5113350
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $60.00 | $37.20 | $30.00 | $7.20 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $205.00 | $127.10 | $0.00 | $127.10 | Paid |
| Totals | $265.00 | $164.30 | $30.00 | $134.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-459671
- 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-032315 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-28: CHOICE-PLUS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 30 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 Medical Group (5090764809). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-08-28 16:12
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$265.00
Plan discount
$100.70
contracted rate
Plan paid
$134.30
You may owe
$30.00
copay, deductible and coinsurance
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-2026-019985 | 2026-07-16 | Desert Rehabilitation Center | $136.00 | Approved |
| CLM-2026-022736 | 2026-05-06 | Desert Internal Medicine Associates | $389.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.