CLM-2026-001744
Canyon Primary Care Associates, Family Medicine. Service 2026-05-10 at office (POS 11). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Margaret Obrien
- Member ID
- UHC-43459-75
- Date of birth
- 1996-11-16
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-415350
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8513
- Coverage period
- 2025-03-01 to present
- Deductible
- $8.54 of $1,500.001%
- Out-of-pocket maximum
- $482.94 of $6,000.008%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1153672351
- Network
- In network
- Rendering NPI
- 5685425766
- Location
- Nashville, TN · TIN 25-1415527
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $319.00 | $197.78 | $30.00 | $167.78 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $257.00 | $159.34 | $0.00 | $159.34 | Paid |
| Totals | $576.00 | $357.12 | $30.00 | $327.12 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-883924
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027484 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-10: SELECT-EPO (EPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 10 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 Primary Care Associates (1153672351). | |
| 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 Associates2026-05-10 18:20
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017113 | 2026-08-21 | Evergreen Medical Group | $488.00 | Approved |
| CLM-2026-029515 | 2026-04-13 | Lakeside Physical Therapy | $273.00 | Approved |
| CLM-2026-013140 | 2026-04-14 | Harbor Physical Therapy | $289.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.