CLM-2026-003389
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-02-20 to 2026-02-22 at inpatient hospital (POS 21). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Roger White
- Member ID
- UHC-38078-45
- Date of birth
- 1948-08-05
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-407531
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5884
- Coverage period
- 2024-10-01 to present
- Deductible
- $325.96 of $500.0065%
- Out-of-pocket maximum
- $836.51 of $2,000.0042%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6406090442
- Network
- Out of network
- Rendering NPI
- 9993332516
- Location
- Austin, TX · TIN 91-5700891
- 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 | $161.00 | $72.45 | — | — | DeniedCO204 |
| Totals | $161.00 | $72.45 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-255529
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-20 to 2026-02-24
- 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-015238 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 41 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 | Fail | CO204 | Billing provider 6406090442 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Internal Medicine Associates2026-02-22 13:33
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-04 02:44
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-255529.pdf3 pages
Itemised statement totalling $161.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 6406090442 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021568 | 2026-06-08 | Mesa Family Practice | $207.00 | Approved |
| CLM-2026-003068 | 2026-05-26 | Desert Reference Lab | $171.00 | Denied |
| CLM-2026-029385 | 2026-03-09 | Evergreen Medical Group | $439.00 | 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
No out-of-network benefit on this plan.