Claims workbench/CLM-2026-031724
Professional claim · CMS-1500 · Provider portal

CLM-2026-031724

Canyon Medical Group, Internal Medicine. Service 2026-06-23 at office (POS 11). Received 2026-07-30.

Approved
Billed
$120.00
1 line
Allowed
$74.40
contract rate applied
Plan pays
$54.40
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Eric Shaw
Member ID
UHC-14709-71
Date of birth
1996-01-06
Identity
Verified4 records, confidence 0.98
Claim record
CLMCLM-428821
Relationship
Spouse, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group NULL
Coverage period
2022-11-01 to present
Deductible
$161.68 of $500.0032%
Out-of-pocket maximum
$460.06 of $2,000.0023%
Copays
office $20.00, specialist $40.00, emergency $350.00
Physical therapy visits
11 of 20 used

Provider

Billing and rendering

Billing provider
Canyon Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
5090764809
Network
In network
Rendering NPI
8106875734
Location
Houston, TX · TIN 52-5113350
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193000Electrocardiogram with interpretation—11$120.00$74.40$20.00$54.40Paid
Totals$120.00$74.40$20.00$54.40
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
Claim header
Patient account
PA-491001
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

CheckResultCodeDetail
Member identityPassAttached to MBR-018476 (verified, link confidence 0.98).
EligibilityPassActive on 2026-06-23: CHOICE-PLUS-PPO (PPO), effective 2022-11-01.
Timely filingPassReceived 37 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Canyon Medical Group (5090764809).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Group2026-06-23 11:33

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$120.00
Plan discount
$45.60
contracted rate
Plan paid
$54.40
You may owe
$20.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0345002026-03-09Lakeside Medical Group$34.00Approved

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.

Review queueMember identity