CLM-2026-004525
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-04-17 to 2026-04-20 at inpatient hospital (POS 21). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Katherine Tucker
- Member ID
- UHC-50556-18
- Date of birth
- 1949-10-27
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-414857
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6099
- Coverage period
- 2024-02-01 to present
- Deductible
- $675.85 of $1,500.0045%
- Out-of-pocket maximum
- $543.43 of $4,500.0012%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6406090442
- Network
- Out of network
- Rendering NPI
- 3710309600
- Location
- Austin, TX · TIN 91-5700891
- Authorisation / referral
- none / REF497684
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 | $212.00 | $95.40 | — | — | DeniedCO204 |
| Totals | $212.00 | $95.40 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-858426
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-17 to 2026-04-20
- 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-031330 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-17: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 29 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 HMO 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 Associates2026-04-20 12:59
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-19 06:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-19 14:39
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-858426.pdf2 pages
Itemised statement totalling $212.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 6406090442 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.