CLM-2026-004701
Canyon Primary Care Associates, Family Medicine. Service 2026-09-30 at office (POS 11). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Pamela Santiago
- Member ID
- UHC-70706-81
- Date of birth
- 1982-04-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410047
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5169
- Coverage period
- 2022-03-01 to 2026-03-11
- Deductible
- $922.36 of $1,500.0061%
- Out-of-pocket maximum
- $694.44 of $3,000.0023%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1153672351
- Network
- In network
- Rendering NPI
- 9656482681
- 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 | $272.00 | $168.64 | — | — | DeniedCO27 |
| Totals | $272.00 | $168.64 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-972898
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-046081 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-30 is after coverage terminated on 2026-03-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 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 Associates2026-09-30 09:44
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-09 01:25
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-09 13:07
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-30 is after coverage terminated on 2026-03-11.
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
Service after coverage termination.