CLM-2026-005439
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-09-05 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Scott Cooper
- Member ID
- UHC-57705-65
- Date of birth
- 2008-02-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407786
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6753
- Coverage period
- 2025-05-01 to present
- Deductible
- $921.52 of $1,500.0061%
- Out-of-pocket maximum
- $631.20 of $4,500.0014%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3068658913
- Network
- In network
- Rendering NPI
- 8844597574
- Location
- San Diego, CA · TIN 88-5368681
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $63.00 | $39.06 | $30.00 | $9.06 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $413.00 | $256.06 | $0.00 | $256.06 | Paid |
| Totals | $476.00 | $295.12 | $30.00 | $265.12 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
- Patient account
- PA-494089
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005339 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-05: CHOICE-PLUS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 36 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 Internal Medicine Associates (3068658913). | |
| 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 Associates2026-09-05 15:54
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022829 | 2026-08-14 | Mesa Clinical Laboratories | $133.00 | Approved |
| CLM-2026-031112 | 2026-01-09 | Sunrise Imaging Center | $914.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.