CLM-2026-033771
Canyon Internal Medicine Associates, Internal Medicine. Service 2026-03-11 to 2026-03-13 at inpatient hospital (POS 21). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Charles Willis
- Member ID
- UHC-75469-91
- Date of birth
- 1954-04-17
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400389
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4408
- Coverage period
- 2023-05-01 to present
- Deductible
- $375.70 of $500.0075%
- Out-of-pocket maximum
- $366.08 of $1,000.0037%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6406090442
- Network
- Out of network
- Rendering NPI
- 6658254712
- Location
- Austin, TX · TIN 91-5700891
- 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 | $177.00 | $79.65 | $79.65 | $0.00 | Paid |
| Totals | $177.00 | $79.65 | $79.65 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-489243
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-11 to 2026-03-13
- 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-025353 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-11: MEDICARE-ADV-A (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 31 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Internal Medicine Associates2026-03-13 11:02
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-489243.pdf5 pages
Itemised statement totalling $177.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.