CLM-2026-021910
Canyon Primary Care Associates, Family Medicine. Service 2025-12-04 at office (POS 11). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Sandra Kim
- Member ID
- UHC-76520-73
- Date of birth
- 1996-01-07
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-404446
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7130
- Coverage period
- 2024-08-01 to 2026-01-14
- Deductible
- $37.30 of $500.007%
- Out-of-pocket maximum
- $74.69 of $1,000.007%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1153672351
- Network
- In network
- Rendering NPI
- 9432403761
- Location
- Nashville, TN · TIN 25-1415527
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $142.00 | $88.04 | $25.00 | $63.04 | Paid |
| Totals | $142.00 | $88.04 | $25.00 | $63.04 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-771264
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-000585 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-04: MEDICARE-ADV-A (MA), effective 2024-08-01, terms 2026-01-14. | |
| Timely filing | Pass | Received 29 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 Primary Care Associates (1153672351). | |
| 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 Associates2025-12-04 09:17
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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-2026-026810 | 2026-01-26 | Evergreen Medical Group | $179.00 | Denied |
| CLM-2026-005606 | 2026-02-22 | Meadow Heart Institute | $1,456.00 | Denied |
| CLM-2026-024670 | 2026-01-18 | Meadow Family Practice | $542.00 | Denied |
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.