CLM-2026-025843
Canyon Primary Care Associates, Family Medicine. Service 2025-09-23 at office (POS 11). Received 2026-02-18.
Member
Resolved through the identity graph
- Member
- Virginia Gibson
- Member ID
- UHC-43822-84
- Date of birth
- 1959-11-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400468
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-2983
- Coverage period
- 2022-11-01 to present
- Deductible
- $201.78 of $500.0040%
- Out-of-pocket maximum
- $375.25 of $2,000.0019%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4536468513
- Network
- In network
- Rendering NPI
- 7613784256
- Location
- Dallas, TX · TIN 25-8447887
- 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 | 90471 | Immunization administration | — | 1 | 1 | $25.00 | $15.50 | — | — | DeniedCO29 |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $188.00 | $116.56 | — | — | DeniedCO29 |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $16.00 | $9.92 | — | — | DeniedCO29 |
| Totals | $229.00 | $141.98 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-816175
- 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-002860 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-23: - (PPO), effective 2022-11-01. | |
| Timely filing | Fail | CO29 | Received 148 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 (4536468513). | |
| 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 Associates2025-09-23 11:52
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-18 03:50
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-18 10:17
Member services inquiry logged on this claim; member asked about the status of payment.
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 148 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014024 | 2025-12-20 | Lakeside Medical Group | $611.00 | 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
Received after the timely-filing limit.