Professional claim · CMS-1500 · Provider portal
CLM-2026-017325
Canyon Medical Group, Internal Medicine. Service 2026-09-30 at office (POS 11). Received 2026-10-11.
Denied
Billed
$387.00
2 lines
Allowed
$239.94
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Grace Burton
- Member ID
- UHC-52024-75
- Date of birth
- 1981-01-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-400370
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3835
- Coverage period
- 2022-04-01 to 2026-08-08
- Deductible
- $228.41 of $1,500.0015%
- Out-of-pocket maximum
- $63.80 of $3,000.002%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 7477360706
- 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 | $70.00 | $43.40 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $317.00 | $196.54 | — | — | DeniedCO27 |
| Totals | $387.00 | $239.94 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
Claim header
- Patient account
- PA-580862
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-031731 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-30 is after coverage terminated on 2026-08-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-09-30 10:46
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-10-11 04:44
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-30 is after coverage terminated on 2026-08-08.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019128 | 2026-02-11 | Unity Community Hospital | $2,544.00 | Denied |
| CLM-2026-031623 | 2026-05-09 | Sunrise Dermatology Clinic | $625.00 | Approved |
| CLM-2026-032117 | 2026-04-16 | Harbor Cardiovascular Associates | $221.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.