CLM-2026-007372
Canyon Medical Group, Internal Medicine. Service 2026-05-30 at office (POS 11). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Joshua Gray
- Member ID
- UHC-40679-05
- Date of birth
- 1994-04-12
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425127
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-3636
- Coverage period
- 2021-07-01 to present
- Deductible
- $3,100.37 of $3,500.0089%
- Out-of-pocket maximum
- $2,033.03 of $7,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 8504491522
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $230.00 | $142.60 | — | — | DeniedCO18 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $348.00 | $215.76 | — | — | DeniedCO18 |
| Totals | $578.00 | $358.36 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-587233
- 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-013673 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-30: UNKNOWN (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-007371: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-05-30 12:48
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-10 01:31
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-007371: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007371 | 2026-05-30 | Canyon Medical Group | $578.00 | Approved |
| CLM-2026-023452 | 2026-04-08 | Mesa Internal Medicine Associates | $60.00 | Approved |
| CLM-2026-017379 | 2026-01-26 | Mesa Medical Group | $228.00 | Approved |
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
Exact duplicate of an earlier submission.