CLM-2026-004782
Canyon Medical Group, Internal Medicine. Service 2026-01-01 at office (POS 11). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Julia Thomas
- Member ID
- UHC-31006-41
- Date of birth
- 1956-07-15
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429309
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2264
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,034.91 of $1,500.0069%
- Out-of-pocket maximum
- $1,386.92 of $3,000.0046%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 2496076656
- Location
- Houston, TX · TIN 52-5113350
- Authorisation / referral
- none / REF656661
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 | 93000 | Electrocardiogram with interpretation | 59 | 1 | 1 | $114.00 | $70.68 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 2 | $60.00 | $37.20 | — | — | Review |
| Totals | $174.00 | $107.88 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-440490
- 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-005836 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-01: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| 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 | Pass | In-network provider Canyon Medical Group (5090764809). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-01-01 10:44
Patient seen for essential (primary) hypertension. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-02-11 04:05
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-11 11:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Medical recordrecords_PA-440490.pdf12 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.