CLM-2026-014901
Canyon Medical Group, Internal Medicine. Service 2026-04-18 at office (POS 11). Received 2026-04-30.
Member
Resolved through the identity graph
- Member
- Julia Ryan
- Member ID
- UHC-57990-23
- Date of birth
- 1988-04-08
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425317
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group -
- Coverage period
- 2021-06-01 to 2026-04-02
- Deductible
- $1,234.19 of $1,500.0082%
- Out-of-pocket maximum
- $1,744.25 of $4,500.0039%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 4953160841
- Location
- Tempe, AZ · TIN 54-1037261
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $87.00 | $53.94 | — | — | DeniedCO27 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $78.00 | $48.36 | — | — | DeniedCO27 |
| Totals | $165.00 | $102.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-261350
- 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 | Pass | Attached to MBR-001153 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-18 is after coverage terminated on 2026-04-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 (8659320484). | |
| 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 Group2026-04-18 10:57
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-04-30 06:43
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-30 17:40
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-18 is after coverage terminated on 2026-04-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004116 | 2026-03-22 | Desert Reference Lab | $131.00 | 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
Service after coverage termination.