CLM-2026-027509
Canyon Medical Group, Internal Medicine. Service 2026-04-12 at office (POS 11). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Emily Silva
- Member ID
- UHC-43687-71
- Date of birth
- 1976-12-22
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-407008
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9182
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,042.51 of $3,500.0030%
- Out-of-pocket maximum
- $5,559.91 of $14,000.0040%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 9250073837
- Location
- Tempe, AZ · TIN 54-1037261
- Authorisation / referral
- none / REF660068
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $66.00 | $40.92 | $25.00 | $15.92 | Paid |
| Totals | $66.00 | $40.92 | $25.00 | $15.92 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-979891
- 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-020896 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-12: NAVIGATE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 5 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 (8659320484). | |
| 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 Group2026-04-12 11:54
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005773 | 2026-09-30 | Riverside Diagnostic Imaging | $2,419.00 | Approved |
| CLM-2026-026542 | 2026-03-08 | Desert Primary Care Associates | $477.00 | Approved |
| CLM-2026-006290 | 2026-03-04 | Unity Imaging Center | $2,164.00 | Denied |
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.