Professional claim · CMS-1500 · EDI 837P
CLM-2026-029099
Canyon Medical Group, Internal Medicine. Service 2025-12-18 at office (POS 11). Received 2026-01-15.
Approved
Billed
$659.00
3 lines
Allowed
$408.58
contract rate applied
Plan pays
$388.58
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Ethan Boyd
- Member ID
- UHC-52979-83
- Date of birth
- 1990-12-17
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-420246
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1165
- Coverage period
- 2021-11-01 to present
- Deductible
- $11.91 of $500.002%
- Out-of-pocket maximum
- $172.73 of $1,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 4513432912
- Location
- Houston, TX · TIN 52-5113350
- Authorisation / referral
- none / REF442571
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 | $68.00 | $42.16 | $20.00 | $22.16 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $331.00 | $205.22 | $0.00 | $205.22 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $260.00 | $161.20 | $0.00 | $161.20 | Paid |
| Totals | $659.00 | $408.58 | $20.00 | $388.58 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
Claim header
- Patient account
- PA-547903
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004487 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-12-18: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 28 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 (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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2025-12-18 16:23
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$659.00
Plan discount
$250.42
contracted rate
Plan paid
$388.58
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019556 | 2026-01-04 | Lakeside Regional Medical Center | $231.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.