CLM-2026-015368
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-03-20 to 2026-03-21 at inpatient hospital (POS 21). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Natalie Elliott
- Member ID
- UHC-09220-55
- Date of birth
- 1978-11-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-413091
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1524
- Coverage period
- 2021-06-01 to present
- Deductible
- $135.77 of $3,500.004%
- Out-of-pocket maximum
- $1,500.67 of $7,000.0021%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3068658913
- Network
- In network
- Rendering NPI
- 6776456280
- Location
- San Diego, CA · TIN 88-5368681
- Authorisation / referral
- none / REF324697
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 | $165.00 | $90.75 | — | — | Review |
| Totals | $165.00 | $90.75 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-630646
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-20 to 2026-03-22
- 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-008367 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-20: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 41 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 Internal Medicine Associates (3068658913). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Internal Medicine Associates2026-03-21 10:40
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-01 02:13
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-01 09:12
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-630646.pdf9 pages
Itemised statement totalling $165.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms re”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012472 | 2026-04-19 | Heritage Family Practice | $3,308.00 | Needs review |
| CLM-2026-026986 | 2026-01-12 | Heritage Family Practice | $25.00 | Approved |
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
Development letter outstanding.