CLM-2026-026276
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-02-02 to 2026-02-04 at inpatient hospital (POS 21). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Vincent Sullivan
- Member ID
- UHC-26763-55
- Date of birth
- 1973-06-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-424643
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6812
- Coverage period
- 2023-10-01 to present
- Deductible
- $216.67 of $500.0043%
- Out-of-pocket maximum
- $475.29 of $1,000.0048%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6406090442
- Network
- Out of network
- Rendering NPI
- 6220570868
- Location
- Austin, TX · TIN 91-5700891
- 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 | $241.00 | $108.45 | $108.45 | $0.00 | Paid |
| Totals | $241.00 | $108.45 | $108.45 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-624515
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-02 to 2026-02-06
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004927 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-02: CHOICE-PLUS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 26 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 Internal Medicine Associates2026-02-04 14:09
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-624515.pdf6 pages
Itemised statement totalling $241.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022355 | 2026-09-19 | Evergreen Reference Lab | $94.00 | Approved |
| CLM-2026-016211 | 2026-07-31 | Evergreen GI Associates | $272.00 | Approved |
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.