CLM-2026-032202
Canyon Medical Group, Internal Medicine. Service 2026-01-02 at office (POS 11). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Jeremy Torres
- Member ID
- UHC-01486-09
- Date of birth
- 1982-06-17
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403353
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8972
- Coverage period
- 2025-06-01 to present
- Deductible
- $9.57 of $1,000.001%
- Out-of-pocket maximum
- $678.27 of $2,000.0034%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8186175484
- Network
- In network
- Rendering NPI
- 8594205303
- Location
- Scottsdale, AZ · TIN 27-1772787
- Authorisation / referral
- none / REF827349
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $247.00 | $153.14 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 2 | $407.00 | $252.34 | — | — | Review |
| Totals | $654.00 | $405.48 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-689780
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-001359 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-02: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 3 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 (8186175484). | |
| 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: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”. 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 Group2026-01-02 10:21
Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-05 00:10
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-05 14:02
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”.
- AI recommendationPended2026-10-21 14:14The claim is pended due to incomplete documentation. The clinical note indicates that the patient was seen for unspecified atrial fibrillation, but the note is dictated and the signature is pending [N1]. Additionally, the system note confirms that the rendering provider's signature is missing, and a development letter has been sent to the provider [N2].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · 5668242b
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000288 | 2026-06-07 | Canyon Clinical Laboratories | $106.00 | Approved |
| CLM-2026-032196 | 2026-02-19 | Summit Counseling Center | $167.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note indicates that the patient was seen for unspecified atrial fibrillation, but the note is dictated and the signature is pending [N1]. Additionally, the system note confirms that the rendering provider's signature is missing, and a development letter has been sent to the provider [N2].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.