CLM-2026-005504
Canyon Reference Lab, Clinical Laboratory. Service 2025-12-03 at independent laboratory (POS 81). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Thomas Luna
- Member ID
- UHC-64102-71
- Date of birth
- 1986-04-10
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-410875
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4137
- Coverage period
- 2025-09-01 to present
- Deductible
- $2,261.12 of $3,500.0065%
- Out-of-pocket maximum
- $24.04 of $10,500.000%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $69.00 | $42.78 | — | — | DeniedCO29 |
| Totals | $69.00 | $42.78 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-172018
- 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-008438 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-03: MEDICARE-ADV-B (MA), effective 2025-09-01. | |
| Timely filing | Fail | CO29 | Received 181 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 (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 Lab2025-12-03 13:19
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-02 05:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-02 10:43
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 13:43Timely filing: Received 181 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018326 | 2026-06-20 | Sunrise Heart Institute | $401.00 | Approved |
| CLM-2026-034181 | 2026-03-03 | Pinecrest Bone and Joint Center | $232.00 | Approved |
| CLM-2026-032957 | 2026-01-16 | Lakeside Regional Medical Center | $1,460.00 | 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.