Claims workbench/CLM-2026-005538

Professional claim · CMS-1500 · EDI 837P

CLM-2026-005538

Canyon Reference Lab, Clinical Laboratory. Service 2026-04-12 at independent laboratory (POS 81). Received 2026-05-30.

DeniedOut of network

Billed

$94.00

2 lines

Allowed

$42.30

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Shirley Baker
Member ID: UHC-45715-13
Date of birth: 1984-05-13
Identity: Verified3 records, confidence 0.96
Claim record: CLMCLM-422458
Relationship: Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-4136
Coverage period: 2022-11-01 to present
Deductible: $213.63 of $1,000.0021%
Out-of-pocket maximum: $422.77 of $3,000.0014%
Copays: office $30.00, specialist $60.00, emergency $350.00
Physical therapy visits: 7 of 20 used

Provider

Billing and rendering

Billing provider: Canyon Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI: 8227331807
Network: Out of network
Rendering NPI: 8227331807
Location: Los Angeles, CA · TIN 88-1576930
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	80053	Comprehensive metabolic panel	—	1	1	$45.00	$20.25	—	—	DeniedCO18
2	80061	Lipid panel	—	1	2	$49.00	$22.05	—	—	DeniedCO18
Totals						$94.00	$42.30	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal
2. N39.0 Urinary tract infection, site not specified

Claim header

Patient account: PA-459318
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-026011 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-04-12: UNKNOWN (PPO), effective 2022-11-01.
Timely filing	Pass		Received 48 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-005537: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		No line requires precertification.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Canyon Reference Lab2026-04-12 15:40
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-05-30 03:24
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-30 09:10
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-005537: same member, date of service, procedures and billing provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023179	2026-06-12	Harbor Endocrine Associates	$258.00	Approved
CLM-2026-005537	2026-04-12	Canyon Reference Lab	$94.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity