CLM-2026-010569
Canyon Medical Group, Internal Medicine. Service 2026-07-13 to 2026-07-14 at inpatient hospital (POS 21). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Peter Herrera
- Member ID
- UHC-90166-98
- Date of birth
- 1941-07-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409638
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0274
- Coverage period
- 2025-09-01 to present
- Deductible
- $141.38 of $1,500.009%
- Out-of-pocket maximum
- $1,787.75 of $4,500.0040%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 2170839122
- Location
- Tempe, AZ · TIN 54-1037261
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $175.00 | $96.25 | $96.25 | $0.00 | Paid |
| Totals | $175.00 | $96.25 | $96.25 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-884102
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-13 to 2026-07-16
- 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-000830 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-13: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 25 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 (8659320484). | |
| 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 Group2026-07-14 17:38
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-884102.pdf8 pages
Itemised statement totalling $175.00 across 1 line.
Explanation of benefits
What the member will see
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
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.