CLM-2026-011177
Canyon GI Associates, Gastroenterology. Service 2026-07-13 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Morgan Denny
- Member ID
- none on golden record
- Date of birth
- 1955-03-02
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429379
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-3982
- Coverage period
- 2023-01-01 to present
- Deductible
- $436.02 of $500.0087%
- Out-of-pocket maximum
- $58.78 of $2,000.003%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 6101588146
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- none / REF219681
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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $342.00 | $188.10 | $76.39 | $111.71 | Paid |
| Totals | $342.00 | $188.10 | $76.39 | $111.71 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-828977
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040889 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-07-13: NAVIGATE-HMO (HMO), effective 2023-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 GI Associates (8906815153). | |
| 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 GI Associates2026-07-13 16:26
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-828977.pdf4 pages
Itemised statement totalling $342.00 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 13:43Eligibility: Active on 2026-07-13: NAVIGATE-HMO (HMO), effective 2023-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011178 | 2026-07-13 | Canyon GI Associates | $342.00 | Needs review |
| CLM-2026-028993 | 2026-07-08 | Mesa Internal Medicine Associates | $291.00 | Approved |
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.