CLM-2026-001969
Canyon Medical Group, Internal Medicine. Service 2026-01-04 at office (POS 11). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Donald Chapman
- Member ID
- UHC-60622-70
- Date of birth
- 2003-08-09
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-429819
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1216
- Coverage period
- 2024-06-01 to present
- Deductible
- $1,090.93 of $3,500.0031%
- Out-of-pocket maximum
- $5,573.95 of $14,000.0040%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 9921619372
- Location
- Tempe, AZ · TIN 54-1037261
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $367.00 | $227.54 | — | — | DeniedCO29 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $60.00 | $37.20 | — | — | DeniedCO29 |
| Totals | $427.00 | $264.74 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-888698
- 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-027797 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-04: MEDICARE-ADV-A (MA), effective 2024-06-01. | |
| Timely filing | Fail | CO29 | Received 112 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 Medical Group (8659320484). | |
| 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 Group2026-01-04 13:19
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-04-26 05:56
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 engineDenied2026-10-22 12:44Timely filing: Received 112 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.