CLM-2026-014861
Canyon Medical Group, Internal Medicine. Service 2026-05-25 at office (POS 11). Received 2026-06-21.
Member
Resolved through the identity graph
- Member
- Emily Chapman
- Member ID
- UHC-47796-81
- Date of birth
- 2008-06-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422517
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3491
- Coverage period
- 2021-07-01 to present
- Deductible
- $638.01 of $2,500.0026%
- Out-of-pocket maximum
- $1,886.78 of $5,000.0038%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 6092616229
- Location
- Phoenix, AZ · TIN 35-9656772
- Authorisation / referral
- none / REF586380
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $282.00 | $174.84 | — | — | PendedIDQ |
| Totals | $282.00 | $174.84 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-805993
- 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 | Fail | IDQ | Member record is in open steward case CASE-003140; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-05-25: CORE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 27 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 Group2026-05-25 10:58
Patient seen for unspecified atrial fibrillation. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-21 04:43
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-805993.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003140; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.