CLM-2026-016738
Canyon Primary Care Associates, Family Medicine. Service 2026-02-13 at office (POS 11). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Eugene Soto
- Member ID
- UHC-38273-80
- Date of birth
- 1991-01-02
- Identity
- Verified4 records, confidence 0.92
- Claim record
- CLMCLM-418234
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0781
- Coverage period
- 2024-09-01 to present
- Deductible
- $356.78 of $500.0071%
- Out-of-pocket maximum
- $395.00 of $1,000.0040%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1153672351
- Network
- In network
- Rendering NPI
- 3277420816
- Location
- Nashville, TN · TIN 25-1415527
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $223.00 | $138.26 | — | — | DeniedCO29 |
| Totals | $223.00 | $138.26 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-663615
- 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-021235 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Fail | CO29 | Received 165 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Primary Care Associates (1153672351). | |
| 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 Primary Care Associates2026-02-13 10:03
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-07-28 03:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 165 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015051 | 2026-07-09 | Riverside Orthopedic Specialists | $3,229.00 | Needs review |
| CLM-2026-027110 | 2026-02-18 | Valley Reference Lab | $161.00 | 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
Received after the timely-filing limit.