CLM-2026-026952
Canyon Medical Group, Internal Medicine. Service 2026-09-11 at office (POS 11). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- David Wang
- Member ID
- UHC-66449-08
- Date of birth
- 1968-08-14
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-422438
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9496
- Coverage period
- 2024-10-01 to present
- Deductible
- $647.15 of $2,500.0026%
- Out-of-pocket maximum
- $2,340.61 of $10,000.0023%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8186175484
- Network
- In network
- Rendering NPI
- 3131843542
- Location
- Scottsdale, AZ · TIN 27-1772787
- 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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $305.00 | $189.10 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1,2 | $65.00 | $40.30 | — | — | Review |
| Totals | $370.00 | $229.40 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-750507
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-025331 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-11: UNKNOWN (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 27 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 (8186175484). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-09-11 16:50
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-10-08 01:23
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-08 10:51
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-750507.pdf13 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.