CLM-2026-028513
Canyon Medical Group, Internal Medicine. Service 2026-09-27 to 2026-09-29 at inpatient hospital (POS 21). Received 2026-11-08.
Member
Resolved through the identity graph
- Member
- Steven Wheeler
- Member ID
- UHC-11820-74
- Date of birth
- 1999-03-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429226
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3875
- Coverage period
- 2024-07-01 to present
- Deductible
- $94.29 of $500.0019%
- Out-of-pocket maximum
- $640.02 of $1,500.0043%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 6635479176
- 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 | $251.00 | $138.05 | — | — | DeniedCO18 |
| Totals | $251.00 | $138.05 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-476039
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-27 to 2026-10-01
- 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-037825 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-27: OPTIONS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028512: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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
- ClinicalProvider: Canyon Medical Group2026-09-29 11:33
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-11-08 01:55
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-11-08 09:24
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-476039.pdf6 pages
Itemised statement totalling $251.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-028512: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028512 | 2026-09-27 | Canyon Medical Group | $251.00 | Approved |
| CLM-2026-021704 | 2026-08-20 | Canyon Primary Care Associates | $304.00 | 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
Exact duplicate of an earlier submission.