Professional claim · CMS-1500 · Paper
CLM-2026-026068
Canyon Medical Group, Internal Medicine. Service 2026-09-14 at office (POS 11). Received 2026-09-23.
Approved
Billed
$391.00
2 lines
Allowed
$242.42
contract rate applied
Plan pays
$217.42
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Bobby Arnold
- Member ID
- UHC-31712-74
- Date of birth
- 1987-06-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430985
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5821
- Coverage period
- 2024-03-01 to present
- Deductible
- $530.49 of $1,000.0053%
- Out-of-pocket maximum
- $854.43 of $4,000.0021%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 5177415747
- Location
- Houston, TX · TIN 52-5113350
- Authorisation / referral
- none / REF223789
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $325.00 | $201.50 | $25.00 | $176.50 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $66.00 | $40.92 | $0.00 | $40.92 | Paid |
| Totals | $391.00 | $242.42 | $25.00 | $217.42 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-769346
- 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-006253 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-14: NAVIGATE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 9 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 (5090764809). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-09-14 11:42
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$391.00
Plan discount
$148.58
contracted rate
Plan paid
$217.42
You may owe
$25.00
copay, deductible and coinsurance
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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.