CLM-2026-034348
Canyon Medical Group, Internal Medicine. Service 2026-03-29 at office (POS 11). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Virginia Clark
- Member ID
- UHC-07844-60
- Date of birth
- 1956-11-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421370
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1620
- Coverage period
- 2023-09-01 to 2026-03-10
- Deductible
- $1,170.76 of $3,500.0033%
- Out-of-pocket maximum
- $2,822.03 of $10,500.0027%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4666126428
- Network
- In network
- Rendering NPI
- 9525995939
- Location
- Phoenix, AZ · TIN 35-9656772
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $350.00 | $217.00 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $43.00 | $26.66 | — | — | DeniedCO27 |
| Totals | $393.00 | $243.66 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-603208
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-023471 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-29 is after coverage terminated on 2026-03-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 Group2026-03-29 10:31
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-20 01:06
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-20 11:19
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-29 is after coverage terminated on 2026-03-10.
Other claims for this member
Same resolved identity
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.