CLM-2026-020504
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-06-05 to 2026-06-06 at inpatient hospital (POS 21). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Dennis Ray
- Member ID
- UHC-11585-25
- Date of birth
- 1961-07-12
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420715
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0529
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,175.92 of $2,500.0047%
- Out-of-pocket maximum
- $2,231.72 of $7,500.0030%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3068658913
- Network
- In network
- Rendering NPI
- 6083879703
- Location
- San Diego, CA · TIN 88-5368681
- 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 | $186.00 | $102.30 | $102.30 | $0.00 | Paid |
| Totals | $186.00 | $102.30 | $102.30 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-957728
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-05 to 2026-06-09
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021384 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-05: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| 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 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Internal Medicine Associates2026-06-06 11:16
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-957728.pdf7 pages
Itemised statement totalling $186.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028344 | 2026-06-01 | Evergreen Dermatology Clinic | $950.00 | Approved |
| CLM-2026-027625 | 2026-04-14 | Pinecrest Regional Medical Center | $2,494.00 | Needs review |
| CLM-2026-027624 | 2026-04-14 | Pinecrest Regional Medical Center | $2,494.00 | Approved |
| CLM-2026-023035 | 2026-03-01 | Sunrise Orthopedic Specialists | $42,280.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.