Professional claim · CMS-1500 · EDI 837P
CLM-2026-005445
Canyon Medical Group, Internal Medicine. Service 2026-07-04 at office (POS 11). Received 2026-08-11.
Approved
Billed
$363.00
2 lines
Allowed
$225.06
contract rate applied
Plan pays
$205.06
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- James Maldonado
- Member ID
- UHC-48927-65
- Date of birth
- 1954-08-19
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421656
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9467
- Coverage period
- 2025-01-01 to present
- Deductible
- $2,240.36 of $2,500.0090%
- Out-of-pocket maximum
- $2,234.20 of $5,000.0045%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 1075403331
- Location
- Houston, TX · TIN 52-5113350
- 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 | $75.00 | $46.50 | $20.00 | $26.50 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $288.00 | $178.56 | $0.00 | $178.56 | Paid |
| Totals | $363.00 | $225.06 | $20.00 | $205.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
Claim header
- Patient account
- PA-400487
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027302 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-04: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 38 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) | 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-07-04 11:08
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$363.00
Plan discount
$137.94
contracted rate
Plan paid
$205.06
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029709 | 2026-08-19 | Meadow Cardiovascular Associates | $572.00 | Denied |
| CLM-2026-029708 | 2026-08-19 | Meadow Cardiovascular Associates | $572.00 | Approved |
| CLM-2026-027821 | 2026-07-04 | Harbor Medical Group | $724.00 | Approved |
| CLM-2026-015232 | 2026-03-11 | Valley Medical Group | $528.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.