CLM-2026-013514
Canyon Medical Group, Internal Medicine. Service 2026-08-12 to 2026-08-16 at inpatient hospital (POS 21). Received 2026-09-18.
Member
Resolved through the identity graph
- Member
- Julie Reynolds
- Member ID
- UHC-23496-10
- Date of birth
- 2003-09-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409317
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4940
- Coverage period
- 2024-09-01 to 2026-02-02
- Deductible
- $78.50 of $500.0016%
- Out-of-pocket maximum
- $579.73 of $2,000.0029%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 5508350464
- 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 | $206.00 | $113.30 | — | — | DeniedCO27 |
| Totals | $206.00 | $113.30 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-358109
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-12 to 2026-08-13
- 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-013104 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-12 is after coverage terminated on 2026-02-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 Group2026-08-16 09:39
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-09-18 03:54
Attachments
Documents received with the claim
- Itemized billitemized_PA-358109.pdf4 pages
Itemised statement totalling $206.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-12 is after coverage terminated on 2026-02-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010345 | 2026-02-10 | Desert Regional Medical Center | $1,871.00 | 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.