CLM-2026-001508
Canyon Medical Group, Internal Medicine. Service 2026-06-29 to 2026-06-30 at inpatient hospital (POS 21). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Theresa Ortiz
- Member ID
- none on golden record
- Date of birth
- 1979-04-04
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425932
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-0230
- Coverage period
- 2023-04-01 to present
- Deductible
- $31.30 of $1,500.002%
- Out-of-pocket maximum
- $972.74 of $4,500.0022%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 1626088516
- Location
- Houston, TX · TIN 52-5113350
- 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $205.00 | $112.75 | — | — | PendedIDQ |
| Totals | $205.00 | $112.75 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-620004
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-29 to 2026-07-03
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002355; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-29: MEDICARE-ADV-A (MA), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 20 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-06-30 15:43
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-620004.pdf2 pages
Itemised statement totalling $205.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002355; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-29: MEDICARE-ADV-A (MA), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.