CLM-2026-029772
Canyon Medical Group, Internal Medicine. Service 2026-07-20 to 2026-07-24 at inpatient hospital (POS 21). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Diego Bishop
- Member ID
- UHC-89423-86
- Date of birth
- 1959-12-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-401181
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7143
- Coverage period
- 2022-05-01 to 2026-08-15
- Deductible
- $567.08 of $1,500.0038%
- Out-of-pocket maximum
- $1,676.32 of $4,500.0037%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 4585883893
- 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 | $212.00 | $116.60 | $116.60 | $0.00 | Paid |
| Totals | $212.00 | $116.60 | $116.60 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- 3. J44.9 COPD, unspecified
- Patient account
- PA-881284
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-20 to 2026-07-23
- 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-022430 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-20: N/A (PPO), effective 2022-05-01, terms 2026-08-15. | |
| Timely filing | Pass | Received 33 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-07-24 09:22
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-881284.pdf7 pages
Itemised statement totalling $212.00 across 1 line.
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-2026-019467 | 2026-09-04 | Lakeside Heart Institute | $272.00 | Denied |
| CLM-2026-029619 | 2026-07-20 | Northgate Heart Institute | $775.00 | Needs review |
| CLM-2026-017342 | 2026-03-08 | Riverside Medical Group | $727.00 | Approved |
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.