CLM-2026-026230
Canyon Medical Group, Internal Medicine. Service 2026-05-23 to 2026-05-25 at inpatient hospital (POS 21). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Ronald Murray
- Member ID
- UHC-21726-19
- Date of birth
- 1953-02-23
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-414417
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9044
- Coverage period
- 2024-08-01 to 2026-02-07
- Deductible
- $527.62 of $1,000.0053%
- Out-of-pocket maximum
- $803.90 of $2,000.0040%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 5885405501
- Location
- Phoenix, AZ · TIN 35-9656772
- 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $210.00 | $115.50 | — | — | DeniedCO27 |
| Totals | $210.00 | $115.50 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-118537
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-23 to 2026-05-25
- 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-032251 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-23 is after coverage terminated on 2026-02-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 0 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 (4666126428). | |
| 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
- SystemSystem: Claims system2026-05-25 01:24
- ClinicalProvider: Canyon Medical Group2026-05-25 11:28
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-25 14:46
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-118537.pdf8 pages
Itemised statement totalling $210.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-23 is after coverage terminated on 2026-02-07.
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
Service after coverage termination.