CLM-2026-002724
Canyon Reference Lab, Clinical Laboratory. Service 2026-01-11 at independent laboratory (POS 81). Received 2026-08-05.
Member
Resolved through the identity graph
- Member
- Vincent Hart
- Member ID
- UHC-21987-76
- Date of birth
- 1959-07-15
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421918
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9030
- Coverage period
- 2025-02-01 to present
- Deductible
- $287.21 of $2,500.0011%
- Out-of-pocket maximum
- $3,459.32 of $10,000.0035%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1357873425
- Network
- In network
- Rendering NPI
- 1357873425
- Location
- Charlotte, NC · TIN 61-7753780
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $59.00 | $36.58 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $51.00 | $31.62 | — | — | DeniedCO29 |
| Totals | $110.00 | $68.20 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-779896
- 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-013949 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-11: MEDICARE-ADV-B (MA), effective 2025-02-01. | |
| Timely filing | Fail | CO29 | Received 206 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Reference Lab (1357873425). | |
| 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 Lab2026-01-11 14:30
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-08-05 00:54
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-05 12:47
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 206 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002701 | 2026-07-05 | Canyon Skin Care Associates | $539.00 | Approved |
| CLM-2026-030311 | 2026-03-15 | Meadow Reference Lab | $67.00 | 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
Received after the timely-filing limit.