CLM-2026-011352
Canyon Medical Group, Internal Medicine. Service 2026-03-09 to 2026-03-10 at inpatient hospital (POS 21). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Ronald West
- Member ID
- UHC-21226-69
- Date of birth
- 2007-07-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-423696
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2934
- Coverage period
- 2023-08-01 to 2026-04-13
- Deductible
- $2,014.85 of $3,500.0058%
- Out-of-pocket maximum
- $1,416.46 of $7,000.0020%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 8264100974
- Location
- Houston, TX · TIN 52-5113350
- 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 | $230.00 | $126.50 | $126.50 | $0.00 | Paid |
| Totals | $230.00 | $126.50 | $126.50 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-904178
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-09 to 2026-03-13
- 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-014106 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-09: NULL (PPO), effective 2023-08-01, terms 2026-04-13. | |
| Timely filing | Pass | Received 4 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 (5090764809). | |
| 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 Group2026-03-10 10:01
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-904178.pdf5 pages
Itemised statement totalling $230.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010179 | 2026-01-23 | Meadow Physical Therapy | $116.00 | Denied |
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.