Professional claim · CMS-1500 · Paper
CLM-2026-033751
Canyon Medical Group, Internal Medicine. Service 2026-02-11 at office (POS 11). Received 2026-02-14.
Approved
Billed
$444.00
3 lines
Allowed
$275.28
contract rate applied
Plan pays
$249.86
approved
Member owes
$25.42
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Larry Singh
- Member ID
- UHC-55360-97
- Date of birth
- 2004-07-15
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-426857
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5533
- Coverage period
- 2023-08-01 to present
- Deductible
- $393.04 of $3,500.0011%
- Out-of-pocket maximum
- $1,149.03 of $14,000.008%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 3656345915
- Location
- Tempe, AZ · TIN 54-1037261
- Authorisation / referral
- none / none
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $41.00 | $25.42 | $25.42 | $0.00 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $295.00 | $182.90 | $0.00 | $182.90 | Paid |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $108.00 | $66.96 | $0.00 | $66.96 | Paid |
| Totals | $444.00 | $275.28 | $25.42 | $249.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
Claim header
- Patient account
- PA-903484
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009560 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-11: NULL (PPO), effective 2023-08-01. | |
| 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 (8659320484). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-02-11 12:51
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$444.00
Plan discount
$168.72
contracted rate
Plan paid
$249.86
You may owe
$25.42
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019063 | 2026-03-24 | Sunrise Physical Therapy | $180.00 | Denied |
| CLM-2026-024454 | 2025-12-29 | Mesa Bone and Joint Center | $243.00 | Needs review |
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.