CLM-2026-006982
Canyon Medical Group, Internal Medicine. Service 2026-05-01 at office (POS 11). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Frances Campbell
- Member ID
- UHC-98486-22
- Date of birth
- 1992-09-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427606
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-0138
- Coverage period
- 2025-08-01 to present
- Deductible
- $812.26 of $3,500.0023%
- Out-of-pocket maximum
- $15.00 of $14,000.000%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 9647241816
- Location
- Tempe, AZ · TIN 54-1037261
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $297.00 | $184.14 | $25.00 | $159.14 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $358.00 | $221.96 | $0.00 | $221.96 | Paid |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $120.00 | $74.40 | $0.00 | $74.40 | Paid |
| Totals | $775.00 | $480.50 | $25.00 | $455.50 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-104728
- 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-019839 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-01: UNKNOWN (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 6 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 (8659320484). | |
| 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 Medical Group2026-05-01 16:06
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-07 02:29
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-07 13:54
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-104728.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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-2026-012921 | 2026-06-15 | Desert Internal Medicine Associates | $620.00 | 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
Authorisation must be confirmed with UM before payment.