CLM-2026-011848
Canyon Reference Lab, Clinical Laboratory. Service 2026-01-01 at independent laboratory (POS 81). Received 2026-04-29.
Member
Resolved through the identity graph
- Member
- Joan Bennett
- Member ID
- UHC-27960-11
- Date of birth
- 1943-02-10
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-425088
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3380
- Coverage period
- 2021-07-01 to present
- Deductible
- $517.27 of $1,000.0052%
- Out-of-pocket maximum
- $963.43 of $3,000.0032%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 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 / REF386161
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 | 80061 | Lipid panel | — | 1 | 1 | $38.00 | $23.56 | — | — | DeniedCO29 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $40.00 | $24.80 | — | — | DeniedCO29 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 2 | $58.00 | $35.96 | — | — | DeniedCO29 |
| Totals | $136.00 | $84.32 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-697670
- 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-010174 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-01: CORE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Fail | CO29 | Received 118 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 Lab2026-01-01 15:35
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-04-29 05:43
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)2026-04-29 09:59
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 13:43Timely filing: Received 118 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028397 | 2026-03-18 | Mesa Family Practice | $447.00 | Approved |
| CLM-2026-000820 | 2026-01-02 | Evergreen Rehabilitation Center | $213.00 | 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.