Professional claim · CMS-1500 · EDI 837P
CLM-2026-014425
Canyon Reference Lab, Clinical Laboratory. Service 2026-07-28 at independent laboratory (POS 81). Received 2026-08-24.
ApprovedOut of network
Billed
$134.00
3 lines
Allowed
$60.30
contract rate applied
Plan pays
$0.00
approved
Member owes
$60.30
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Joseph Porter
- Member ID
- none on golden record
- Date of birth
- 2007-06-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428587
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-4463
- Coverage period
- 2023-07-01 to present
- Deductible
- $327.06 of $1,000.0033%
- Out-of-pocket maximum
- $623.40 of $3,000.0021%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $41.00 | $18.45 | $18.45 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1,2 | $31.00 | $13.95 | $13.95 | $0.00 | Paid |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1 | $62.00 | $27.90 | $27.90 | $0.00 | Paid |
| Totals | $134.00 | $60.30 | $60.30 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-481256
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-042445 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-07-28: OPTIONS-PPO (PPO), effective 2023-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 27 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 | 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Reference Lab2026-07-28 16:07
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$134.00
Plan discount
$73.70
out-of-network allowance
Plan paid
$0.00
You may owe
$60.30
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-07-28: OPTIONS-PPO (PPO), effective 2023-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.