CLM-2026-008159
Canyon Primary Care Associates, Family Medicine. Service 2026-02-01 at office (POS 11). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Santiago Welch
- Member ID
- UHC-58279-63
- Date of birth
- 2005-05-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423754
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7107
- Coverage period
- 2024-08-01 to 2026-01-07
- Deductible
- $448.49 of $1,500.0030%
- Out-of-pocket maximum
- $230.11 of $4,500.005%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2780458347
- Network
- In network
- Rendering NPI
- 5657597535
- Location
- Miami, FL · TIN 49-9122267
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $247.00 | $153.14 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | — | — | DeniedCO27 |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $26.00 | $16.12 | — | — | DeniedCO27 |
| Totals | $465.00 | $288.30 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-885302
- 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-018086 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-01 is after coverage terminated on 2026-01-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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 Primary Care Associates (2780458347). | |
| 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 Primary Care Associates2026-02-01 12:37
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-07 05:11
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-07 14:18
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 12:44Eligibility: Date of service 2026-02-01 is after coverage terminated on 2026-01-07.
Other claims for this member
Same resolved identity
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
Service after coverage termination.