CLM-2026-024730
Canyon Primary Care Associates, Family Medicine. Service 2025-09-04 at office (POS 11). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Jeremy Brown
- Member ID
- UHC-45612-99
- Date of birth
- 1990-07-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-404338
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4671
- Coverage period
- 2022-05-01 to present
- Deductible
- $723.99 of $1,000.0072%
- Out-of-pocket maximum
- $1,379.45 of $4,000.0034%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1153672351
- Network
- In network
- Rendering NPI
- 9786178183
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $294.00 | $182.28 | — | — | DeniedCO29 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $219.00 | $135.78 | — | — | DeniedCO29 |
| Totals | $513.00 | $318.06 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-420200
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005623 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-04: MEDICARE-ADV-B (MA), effective 2022-05-01. | |
| Timely filing | Fail | CO29 | Received 136 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Associates2025-09-04 17:52
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-01-18 04:08
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-18 11:56
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 136 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.