CLM-2026-008068
Canyon Medical Group, Internal Medicine. Service 2026-04-20 at office (POS 11). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Meria Hansen
- Member ID
- UHC-89653-21
- Date of birth
- 1983-11-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405676
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6804
- Coverage period
- 2021-10-01 to present
- Deductible
- $232.70 of $500.0047%
- Out-of-pocket maximum
- $550.74 of $2,000.0028%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 7369570917
- Location
- Houston, TX · TIN 52-5113350
- Authorisation / referral
- none / REF387020
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 | $85.00 | $52.70 | — | — | DeniedCO18 |
| Totals | $85.00 | $52.70 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-810857
- 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-032246 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-20: NAVIGATE-HMO (HMO), effective 2021-10-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-008067: 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 Group2026-04-20 18:17
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-06-06 06:09
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-06 17:07
Escalated to nurse reviewer for clinical opinion.
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-2026-008067: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008067 | 2026-04-20 | Canyon Medical Group | $85.00 | 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.