CLM-2026-001237
Canyon Reference Lab, Clinical Laboratory. Service 2026-09-05 at independent laboratory (POS 81). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Karen Anderson
- Member ID
- UHC-48865-86
- Date of birth
- 1974-08-20
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-418053
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3758
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,540.14 of $2,500.0062%
- Out-of-pocket maximum
- $761.20 of $7,500.0010%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8227331807
- Network
- Out of network
- Rendering NPI
- 8227331807
- Location
- Los Angeles, CA · TIN 88-1576930
- Authorisation / referral
- none / REF866981
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 | 87086 | Urine culture | — | 1 | 1 | $64.00 | $28.80 | — | — | DeniedCO204 |
| Totals | $64.00 | $28.80 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-596763
- 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-001538 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-05: CORE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 37 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 | Fail | CO204 | Billing provider 8227331807 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Reference Lab2026-09-05 13:46
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-12 01:25
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-12 17:41
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8227331807 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016428 | 2025-11-28 | Canyon Medical Group | $86.00 | 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
No out-of-network benefit on this plan.