CLM-2026-006657
Canyon Reference Lab, Clinical Laboratory. Service 2026-09-21 at independent laboratory (POS 81). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Natalie Bennett
- Member ID
- UHC-71271-45
- Date of birth
- 1992-11-25
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-431665
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9067
- Coverage period
- 2023-02-01 to present
- Deductible
- $750.76 of $3,500.0021%
- Out-of-pocket maximum
- $4,830.59 of $10,500.0046%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 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 / 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 | $81.00 | $36.45 | — | — | DeniedCO204 |
| 2 | 87086 | Urine culture | — | 1 | 2 | $34.00 | $15.30 | — | — | DeniedCO204 |
| Totals | $115.00 | $51.75 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-731873
- 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-005324 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-21: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 6 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 | Fail | CO204 | Billing provider 8227331807 is out of network and the EPO 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 Lab2026-09-21 12:04
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-27 05:41
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8227331807 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.