Claims workbench/CLM-2026-011909
Professional claim · CMS-1500 · EDI 837P

CLM-2026-011909

Canyon Medical Group, Internal Medicine. Service 2026-05-08 at office (POS 11). Received 2026-05-24.

Approved
Billed
$314.00
1 line
Allowed
$194.68
contract rate applied
Plan pays
$169.68
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Aisha Garza
Member ID
UHC-00750-76
Date of birth
2000-11-19
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-408589
Relationship
Child, Gilbert, AZ

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-4152
Coverage period
2023-08-01 to present
Deductible
$248.19 of $500.0050%
Out-of-pocket maximum
$620.85 of $2,000.0031%
Copays
office $25.00, specialist $50.00, emergency $350.00
Physical therapy visits
12 of 20 used

Provider

Billing and rendering

Billing provider
Canyon Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
4666126428
Network
In network
Rendering NPI
8870880167
Location
Phoenix, AZ · TIN 35-9656772
Authorisation / referral
none / REF572718

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199215Office visit, established patient, high complexity—11$314.00$194.68$25.00$169.68Paid
Totals$314.00$194.68$25.00$169.68
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. I48.91 Unspecified atrial fibrillation
Claim header
Patient account
PA-469363
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-026432 (verified, link confidence 1.00).
EligibilityPassActive on 2026-05-08: CORE-HMO (HMO), effective 2023-08-01.
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Canyon Medical Group (4666126428).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Canyon Medical Group2026-05-08 09:59

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$314.00
Plan discount
$119.32
contracted rate
Plan paid
$169.68
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity