CLM-2026-031905
Canyon Medical Group, Internal Medicine. Service 2026-03-26 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Martha Romero
- Member ID
- UHC-86120-37
- Date of birth
- 1971-12-09
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-404240
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group -
- Coverage period
- 2025-04-01 to present
- Deductible
- $298.09 of $1,000.0030%
- Out-of-pocket maximum
- $313.11 of $3,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 7346053268
- Location
- Phoenix, AZ · TIN 35-9656772
- Authorisation / referral
- none / REF315340
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $288.00 | $178.56 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 2 | $216.00 | $133.92 | — | — | Review |
| Totals | $504.00 | $312.48 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-151061
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026232 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-03-26: NAVIGATE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 21 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 (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 | Review | CO16 | Documentation incomplete: “Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-03-26 18:22
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-16 06:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-16 09:44
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms re”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034187 | 2026-06-21 | Meadow Family Practice | $414.00 | Approved |
| CLM-2026-025309 | 2026-03-28 | Unity Reference Lab | $132.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.