CLM-2026-011630
Canyon Medical Group, Internal Medicine. Service 2026-05-19 at office (POS 11). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Julia McDonald
- Member ID
- UHC-85079-53
- Date of birth
- 1955-06-09
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-408169
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group UNKNOWN
- Coverage period
- 2024-12-01 to 2026-02-18
- Deductible
- $805.79 of $1,500.0054%
- Out-of-pocket maximum
- $2,102.70 of $4,500.0047%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 9685299403
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $364.00 | $225.68 | — | — | DeniedCO27 |
| Totals | $413.00 | $256.06 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-998302
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035958 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-19 is after coverage terminated on 2026-02-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 Group2026-05-19 11:11
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-23 05:47
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-23 17:44
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-19 is after coverage terminated on 2026-02-18.
Other claims for this member
Same resolved identity
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.