CLM-2026-026728
Canyon Medical Group, Internal Medicine. Service 2025-08-11 to 2025-08-14 at inpatient hospital (POS 21). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Nathan Hall
- Member ID
- UHC-65209-99
- Date of birth
- 1939-08-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410490
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9652
- Coverage period
- 2024-01-01 to present
- Deductible
- $261.29 of $500.0052%
- Out-of-pocket maximum
- $363.37 of $1,000.0036%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 2679244675
- Location
- Houston, TX · TIN 52-5113350
- 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 | $249.00 | $136.95 | — | — | DeniedCO29 |
| Totals | $249.00 | $136.95 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-797678
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-08-11 to 2025-08-13
- 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-006812 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-08-11: NULL (PPO), effective 2024-01-01. | |
| Timely filing | Fail | CO29 | Received 161 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 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2025-08-14 18:10
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-22 06:54
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)2026-01-22 11:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-797678.pdf4 pages
Itemised statement totalling $249.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 161 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008923 | 2026-08-26 | Northgate Primary Care Associates | $312.00 | Approved |
| CLM-2026-016590 | 2026-04-25 | Northgate Internal Medicine Associates | $222.00 | 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.