CLM-2026-034461
Canyon Medical Group, Internal Medicine. Service 2026-02-18 at office (POS 11). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Robert Weber
- Member ID
- UHC-94741-69
- Date of birth
- 1982-03-12
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407695
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6366
- Coverage period
- 2021-09-01 to present
- Deductible
- $117.15 of $1,000.0012%
- Out-of-pocket maximum
- $831.76 of $3,000.0028%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8659320484
- Network
- In network
- Rendering NPI
- 9239995910
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $235.00 | $145.70 | $20.00 | $125.70 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $342.00 | $212.04 | $0.00 | $212.04 | Paid |
| Totals | $577.00 | $357.74 | $20.00 | $337.74 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-860489
- 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-003015 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-18: NULL (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 28 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Medical Group2026-02-18 18:17
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
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-2026-009925 | 2025-12-28 | Mesa Medical Group | $41.00 | Denied |
| CLM-2026-032751 | 2026-03-02 | Lakeside Medical Group | $287.00 | Approved |
| CLM-2026-034462 | 2026-02-18 | Canyon Medical Group | $577.00 | Needs review |
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.