CLM-2026-025575
Canyon Community Hospital, Emergency Medicine. Service 2026-03-24 at emergency room (POS 23). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Kathryn Gonzalez
- Member ID
- UHC-37963-95
- Date of birth
- 1946-10-27
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-401378
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8596
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,114.79 of $1,500.0074%
- Out-of-pocket maximum
- $726.26 of $4,500.0016%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 9109847134
- Network
- Out of network
- Rendering NPI
- 9109847134
- Location
- Phoenix, AZ · TIN 21-6618841
- 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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $196.00 | $88.20 | $88.20 | $0.00 | Paid |
| Totals | $196.00 | $88.20 | $88.20 | $0.00 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- Patient account
- PA-420906
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-026404 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-24: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 25 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Community Hospital2026-03-24 16:12
Established patient presents with pneumonia, unspecified organism; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-420906.pdf4 pages
Itemised statement totalling $196.00 across 1 line.
- Er reported_report_PA-420906.pdf3 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
- AI recommendation recordedcli_adjudicator2026-10-21 13:39 · 061c3437
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028368 | 2026-07-15 | Desert Internal Medicine Associates | $271.00 | 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.