CLM-2026-002754
Canyon Reference Lab, Clinical Laboratory. Service 2025-10-06 at independent laboratory (POS 81). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Jerry Romero
- Member ID
- UHC-98312-99
- Date of birth
- 1964-03-24
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-412845
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5539
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,569.72 of $3,500.0073%
- Out-of-pocket maximum
- $3,838.54 of $10,500.0037%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 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 / REF883872
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 | $50.00 | $22.50 | — | — | DeniedCO29 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $65.00 | $29.25 | — | — | DeniedCO29 |
| 3 | 87086 | Urine culture | — | 1 | 1 | $52.00 | $23.40 | — | — | DeniedCO29 |
| Totals | $167.00 | $75.15 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-468693
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023099 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-10-06: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Fail | CO29 | Received 175 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 | 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 Lab2025-10-06 10:28
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-30 03:59
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
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 175 days after the last date of service (limit 90). Provider 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-2026-016075 | 2026-06-03 | Evergreen Orthopedic Specialists | $5,950.00 | Approved |
| CLM-2026-013531 | 2026-06-03 | Desert Regional Medical Center | $951.00 | Needs review |
| CLM-2026-017055 | 2026-02-27 | Canyon Reference Lab | $141.00 | Needs review |
| CLM-2026-017054 | 2026-02-27 | Canyon Reference Lab | $141.00 | Approved |
| CLM-2026-033335 | 2026-03-24 | Canyon Heart Institute | $703.00 | Denied |
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.