CLM-2026-016867
Canyon Medical Group, Internal Medicine. Service 2026-08-17 to 2026-08-19 at inpatient hospital (POS 21). Received 2026-09-18.
Member
Resolved through the identity graph
- Member
- Anna Dunn
- Member ID
- UHC-36655-13
- Date of birth
- 1979-05-15
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-410430
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2304
- Coverage period
- 2023-07-01 to 2026-07-27
- Deductible
- $711.36 of $1,000.0071%
- Out-of-pocket maximum
- $359.93 of $3,000.0012%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8186175484
- Network
- In network
- Rendering NPI
- 1987416264
- Location
- Scottsdale, AZ · TIN 27-1772787
- Authorisation / referral
- none / none
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 | $161.00 | $88.55 | — | — | DeniedCO27 |
| Totals | $161.00 | $88.55 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-225753
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-17 to 2026-08-21
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015284 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-17 is after coverage terminated on 2026-07-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 30 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 (8186175484). | |
| 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 Group2026-08-19 11:09
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-09-18 01:54
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-18 08:08
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-225753.pdf4 pages
Itemised statement totalling $161.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-17 is after coverage terminated on 2026-07-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003455 | 2026-08-22 | Unity Family Practice | $557.00 | Denied |
| CLM-2026-011328 | 2026-02-10 | Evergreen Clinical Laboratories | $43.00 | 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.