CLM-2026-011485
Canyon Medical Group, Internal Medicine. Service 2026-03-05 at office (POS 11). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- William Black
- Member ID
- UHC-48987-35
- Date of birth
- 1967-03-21
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-412834
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0440
- Coverage period
- 2021-07-01 to 2026-02-14
- Deductible
- $300.04 of $1,500.0020%
- Out-of-pocket maximum
- $1,929.05 of $4,500.0043%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 8035864809
- Location
- Phoenix, AZ · TIN 35-9656772
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $399.00 | $247.38 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $240.00 | $148.80 | — | — | DeniedCO27 |
| Totals | $639.00 | $396.18 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-829633
- 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-012887 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-05 is after coverage terminated on 2026-02-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 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 (4666126428). | |
| 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 Group2026-03-05 16:44
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-04-11 04:43
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-11 13:35
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-05 is after coverage terminated on 2026-02-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027341 | 2026-04-01 | Heritage Rehabilitation Center | $468.00 | Denied |
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
Service after coverage termination.