CLM-2026-005062
Canyon Reference Lab, Clinical Laboratory. Service 2026-03-07 at independent laboratory (POS 81). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Jacob Holmes
- Member ID
- none on golden record
- Date of birth
- 1993-04-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401849
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0237
- Coverage period
- 2023-10-01 to 2026-03-10
- Deductible
- $1,022.47 of $2,500.0041%
- Out-of-pocket maximum
- $1,813.51 of $5,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $65.00 | $40.30 | $40.30 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $40.00 | $24.80 | $24.80 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $78.00 | $48.36 | $48.36 | $0.00 | Paid |
| 4 | 85025 | Complete blood count with differential | — | 1 | 1 | $54.00 | $33.48 | $33.48 | $0.00 | Paid |
| Totals | $237.00 | $146.94 | $146.94 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-913326
- 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-020574 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-03-07: NULL (PPO), effective 2023-10-01, terms 2026-03-10. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 16 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) | 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 Lab2026-03-07 10:27
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
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 13:43Eligibility: Active on 2026-03-07: NULL (PPO), effective 2023-10-01, terms 2026-03-10. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007027 | 2026-02-06 | Canyon Reference Lab | $151.00 | Approved |
| CLM-2026-003357 | 2026-02-09 | Northgate Medical Group | $278.00 | Approved |
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.