CLM-2026-033040
Canyon Medical Group, Internal Medicine. Service 2026-10-04 at office (POS 11). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Edward Delgado
- Member ID
- UHC-98565-10
- Date of birth
- 1986-01-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-406788
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4393
- Coverage period
- 2025-10-01 to 2026-08-12
- Deductible
- $799.16 of $1,000.0080%
- Out-of-pocket maximum
- $1,320.18 of $3,000.0044%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5090764809
- Network
- In network
- Rendering NPI
- 2029986496
- Location
- Houston, TX · TIN 52-5113350
- Authorisation / referral
- none / REF545280
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 | $351.00 | $217.62 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $87.00 | $53.94 | — | — | DeniedCO27 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $298.00 | $184.76 | — | — | DeniedCO27 |
| Totals | $736.00 | $456.32 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-635471
- 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-004046 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-04 is after coverage terminated on 2026-08-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Group2026-10-04 18:31
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-16 04:31
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-04 is after coverage terminated on 2026-08-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018307 | 2026-08-06 | Unity Digestive Health Center | $321.00 | Approved |
| CLM-2026-022309 | 2026-02-15 | Summit Endocrine Associates | $659.00 | Approved |
| CLM-2026-019188 | 2026-02-16 | Pinecrest Physical Therapy | $287.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.