CLM-2026-011205
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-01-10 to 2026-01-12 at inpatient hospital (POS 21). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Betty Rojas
- Member ID
- UHC-59588-79
- Date of birth
- 1976-12-27
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-411316
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2268
- Coverage period
- 2023-10-01 to present
- Deductible
- $906.88 of $1,500.0060%
- Out-of-pocket maximum
- $2,892.15 of $6,000.0048%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6406090442
- Network
- Out of network
- Rendering NPI
- 7904663771
- Location
- Austin, TX · TIN 91-5700891
- Authorisation / referral
- none / REF783322
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 | $242.00 | $108.90 | — | — | DeniedCO29 |
| Totals | $242.00 | $108.90 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-909535
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-10 to 2026-01-13
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010963 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-01-10: CORE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Fail | CO29 | Received 111 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 6406090442 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Internal Medicine Associates2026-01-12 17:27
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-05-03 06:34
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-909535.pdf7 pages
Itemised statement totalling $242.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 111 days after the last date of service (limit 90). Provider network: Billing provider 6406090442 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002248 | 2026-09-09 | Northgate Internal Medicine Associates | $474.00 | Approved |
| CLM-2026-030442 | 2026-05-28 | Unity Primary Care Associates | $260.00 | Approved |
| CLM-2026-001174 | 2025-12-30 | Riverside GI Associates | $2,992.00 | Approved |
| CLM-2026-025926 | 2026-02-04 | Desert Medical Group | $251.00 | 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
Received after the timely-filing limit.