CLM-2026-020823
Canyon Primary Care Associates, Family Medicine. Service 2026-10-03 at office (POS 11). Received 2026-10-24.
Member
Resolved through the identity graph
- Member
- Kelly Powell
- Member ID
- UHC-57639-35
- Date of birth
- 1984-05-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418075
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4575
- Coverage period
- 2024-12-01 to present
- Deductible
- $379.39 of $1,500.0025%
- Out-of-pocket maximum
- $652.33 of $4,500.0014%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2780458347
- Network
- In network
- Rendering NPI
- 6247468609
- Location
- Miami, FL · TIN 49-9122267
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $237.00 | $146.94 | — | — | DeniedCO18 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $307.00 | $190.34 | — | — | DeniedCO18 |
| Totals | $544.00 | $337.28 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-475057
- 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-011467 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-03: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-020822: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Primary Care Associates (2780458347). | |
| 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 Associates2026-10-03 13:47
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-10-24 02:23
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-020822: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020822 | 2026-10-03 | Canyon Primary Care Associates | $544.00 | Approved |
| CLM-2026-018413 | 2026-07-27 | Unity Digestive Health Center | $2,598.00 | 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
Exact duplicate of an earlier submission.