CLM-2026-021805
Canyon Medical Group, Internal Medicine. Service 2026-02-18 to 2026-02-19 at inpatient hospital (POS 21). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Ruth Harper
- Member ID
- UHC-27779-17
- Date of birth
- 1949-07-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408056
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0616
- Coverage period
- 2024-05-01 to present
- Deductible
- $128.11 of $500.0026%
- Out-of-pocket maximum
- $252.70 of $1,000.0025%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 1913281261
- Location
- Phoenix, AZ · TIN 35-9656772
- Authorisation / referral
- none / REF303221
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 | $168.00 | $92.40 | $92.40 | $0.00 | Paid |
| Totals | $168.00 | $92.40 | $92.40 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-481246
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-18 to 2026-02-21
- 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-017245 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-18: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 12 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 (4666126428). | |
| 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 Group2026-02-19 10:06
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-481246.pdf3 pages
Itemised statement totalling $168.00 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-2026-019701 | 2026-08-08 | Summit Counseling Center | $790.00 | Needs review |
| CLM-2026-015804 | 2026-02-22 | Heritage Primary Care Associates | $460.00 | 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.