CLM-2026-003745
Canyon Reference Lab, Clinical Laboratory. Service 2026-03-26 at independent laboratory (POS 81). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Peter Arnold
- Member ID
- UHC-08427-88
- Date of birth
- 1994-08-02
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-417022
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-5625
- Coverage period
- 2024-01-01 to 2026-06-23
- Deductible
- $299.94 of $1,500.0020%
- Out-of-pocket maximum
- $1,087.34 of $3,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2842605471
- Network
- In network
- Rendering NPI
- 2842605471
- Location
- Denver, CO · TIN 30-7666954
- 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 | 80061 | Lipid panel | 59 | 1 | 1 | $82.00 | $50.84 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | 59 | 1 | 1,2 | $70.00 | $43.40 | — | — | Review |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $63.00 | $39.06 | — | — | Review |
| 4 | 87086 | Urine culture | 25 | 1 | 1,2 | $39.00 | $24.18 | — | — | Review |
| Totals | $254.00 | $157.48 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-166508
- 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-029654 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-26: - (PPO), effective 2024-01-01, terms 2026-06-23. | |
| Timely filing | Pass | Received 43 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 Reference Lab (2842605471). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Lab2026-03-26 11:28
Patient seen for hyperlipidemia, unspecified. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-05-08 03:29
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-166508.pdf18 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.