Professional claim · CMS-1500 · EDI 837P
CLM-2026-013758
Canyon Medical Group, Internal Medicine. Service 2026-02-24 at office (POS 11). Received 2026-03-03.
Approved
Billed
$439.00
2 lines
Allowed
$272.18
contract rate applied
Plan pays
$252.18
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Sara Franklin
- Member ID
- UHC-76769-82
- Date of birth
- 1955-09-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-413733
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6375
- Coverage period
- 2023-07-01 to present
- Deductible
- $307.80 of $500.0062%
- Out-of-pocket maximum
- $196.11 of $1,000.0020%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 9582491699
- Location
- Phoenix, AZ · TIN 35-9656772
- Authorisation / referral
- none / REF798181
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 | $359.00 | $222.58 | $20.00 | $202.58 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $80.00 | $49.60 | $0.00 | $49.60 | Paid |
| Totals | $439.00 | $272.18 | $20.00 | $252.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
Claim header
- Patient account
- PA-452334
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001223 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-24: CORE-HMO (HMO), effective 2023-07-01. | |
| Timely filing | Pass | Received 7 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-02-24 18:14
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$439.00
Plan discount
$166.82
contracted rate
Plan paid
$252.18
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033218 | 2026-02-06 | Unity Internal Medicine Associates | $422.00 | Denied |
| CLM-2026-003588 | 2026-01-06 | Unity Cardiovascular Associates | $340.00 | Approved |
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.