CLM-2026-012439
Canyon Primary Care Associates, Family Medicine. Service 2026-01-12 at office (POS 11). Received 2026-02-24.
Member
Resolved through the identity graph
- Member
- Matthew Romero
- Member ID
- UHC-57072-21
- Date of birth
- 1972-07-08
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-409349
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7902
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,831.17 of $3,500.0052%
- Out-of-pocket maximum
- $4,203.20 of $14,000.0030%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4536468513
- Network
- In network
- Rendering NPI
- 9290951331
- Location
- Dallas, TX · TIN 25-8447887
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $239.00 | $148.18 | — | — | DeniedCO18 |
| 2 | 36415 | Venipuncture | 25 | 1 | 2 | $24.00 | $14.88 | — | — | DeniedCO18 |
| Totals | $263.00 | $163.06 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-810380
- 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-000076 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-12: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012438: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Primary Care Associates (4536468513). | |
| 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 Primary Care Associates2026-01-12 10:58
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-24 05:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-012438: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003272 | 2026-02-11 | Northgate Clinical Laboratories | $46.00 | Approved |
| CLM-2026-012438 | 2026-01-12 | Canyon Primary Care Associates | $263.00 | 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
Exact duplicate of an earlier submission.