Professional claim · CMS-1500 · EDI 837P
CLM-2026-008052
Canyon Medical Group, Internal Medicine. Service 2026-05-09 at office (POS 11). Received 2026-05-22.
Approved
Billed
$722.00
3 lines
Allowed
$447.64
contract rate applied
Plan pays
$422.64
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Lori Fowler
- Member ID
- UHC-41558-85
- Date of birth
- 1972-10-21
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-405496
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9971
- Coverage period
- 2024-08-01 to present
- Deductible
- $303.46 of $3,500.009%
- Out-of-pocket maximum
- $342.98 of $7,000.005%
- Copays
- office $25.00, 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
- 8666504773
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $96.00 | $59.52 | $25.00 | $34.52 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $362.00 | $224.44 | $0.00 | $224.44 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $264.00 | $163.68 | $0.00 | $163.68 | Paid |
| Totals | $722.00 | $447.64 | $25.00 | $422.64 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
Claim header
- Patient account
- PA-477348
- 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-031867 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-05-09: OPTIONS-PPO (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 13 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 Group2026-05-09 18:30
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$722.00
Plan discount
$274.36
contracted rate
Plan paid
$422.64
You may owe
$25.00
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-2026-024703 | 2026-08-04 | Lakeside Physical Therapy | $241.00 | Approved |
| CLM-2026-023522 | 2026-08-19 | Pinecrest Bone and Joint Center | $43,974.00 | Needs review |
| CLM-2026-008053 | 2026-05-09 | Canyon Medical Group | $722.00 | Denied |
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.