CLM-2026-007973
Canyon Reference Lab, Clinical Laboratory. Service 2026-08-08 at independent laboratory (POS 81). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Joyce Morrison
- Member ID
- UHC-80236-49
- Date of birth
- 1976-09-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412888
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1917
- Coverage period
- 2022-10-01 to 2026-06-12
- Deductible
- $727.29 of $1,000.0073%
- Out-of-pocket maximum
- $1,435.32 of $3,000.0048%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 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 / REF758735
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 | $62.00 | $27.90 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | 25 | 1 | 2 | $67.00 | $30.15 | — | — | DeniedCO27 |
| Totals | $129.00 | $58.05 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-212716
- 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-022943 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-08 is after coverage terminated on 2026-06-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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 HMO 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 Lab2026-08-08 13:19
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-08-27 01:01
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-27 10:25
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-08 is after coverage terminated on 2026-06-12. Provider network: Billing provider 8227331807 is out of network and the HMO 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
Service after coverage termination.