Professional claim · CMS-1500 · Provider portal
CLM-2026-020341
Canyon Medical Group, Internal Medicine. Service 2026-03-31 at office (POS 11). Received 2026-04-14.
Approved
Billed
$355.00
2 lines
Allowed
$220.10
contract rate applied
Plan pays
$195.10
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Beverly Warren
- Member ID
- UHC-50109-81
- Date of birth
- 1949-07-15
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431807
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group -
- Coverage period
- 2024-03-01 to present
- Deductible
- $2,140.62 of $2,500.0086%
- Out-of-pocket maximum
- $50.89 of $10,000.001%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8186175484
- Network
- In network
- Rendering NPI
- 7816138433
- Location
- Scottsdale, AZ · TIN 27-1772787
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $295.00 | $182.90 | $25.00 | $157.90 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $60.00 | $37.20 | $0.00 | $37.20 | Paid |
| Totals | $355.00 | $220.10 | $25.00 | $195.10 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-511576
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012231 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-31: MEDICARE-ADV-B (MA), effective 2024-03-01. | |
| Timely filing | Pass | Received 14 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-03-31 11:15
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$355.00
Plan discount
$134.90
contracted rate
Plan paid
$195.10
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031542 | 2026-04-12 | Heritage GI Associates | $284.00 | Approved |
| CLM-2026-031077 | 2026-02-13 | Lakeside Orthopedic Specialists | $300.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.