CLM-2026-009831
Canyon Medical Group, Internal Medicine. Service 2026-03-21 at office (POS 11). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Jason Morales
- Member ID
- UHC-98668-81
- Date of birth
- 1947-11-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-406279
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group -
- Coverage period
- 2022-04-01 to present
- Deductible
- $2,360.55 of $3,500.0067%
- Out-of-pocket maximum
- $4,226.00 of $10,500.0040%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8186175484
- Network
- In network
- Rendering NPI
- 4785492727
- Location
- Scottsdale, AZ · TIN 27-1772787
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $68.00 | $42.16 | $40.00 | $2.16 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $313.00 | $194.06 | $0.00 | $194.06 | Paid |
| Totals | $381.00 | $236.22 | $40.00 | $196.22 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-365670
- 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-010408 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-21: CHOICE-PLUS-PPO (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 12 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 (8186175484). | |
| 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 Group2026-03-21 14:25
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
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
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
Clean claim, priced at contract rate.