CLM-2026-032875
Canyon Medical Group, Internal Medicine. Service 2026-02-27 to 2026-02-28 at inpatient hospital (POS 21). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Philip Marshall
- Member ID
- UHC-88317-89
- Date of birth
- 1939-03-28
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-402457
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2440
- Coverage period
- 2023-02-01 to present
- Deductible
- $388.71 of $2,500.0016%
- Out-of-pocket maximum
- $1,057.62 of $10,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 9621639498
- Location
- Phoenix, AZ · TIN 35-9656772
- 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 | $173.00 | $95.15 | $95.15 | $0.00 | Paid |
| Totals | $173.00 | $95.15 | $95.15 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-758841
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-27 to 2026-03-02
- 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-009573 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-27: CHOICE-PLUS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 20 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 | 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 Group2026-02-28 11:15
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-758841.pdf6 pages
Itemised statement totalling $173.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020715 | 2025-12-25 | Sunrise Behavioral Health | $218.00 | 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.