CLM-2026-015581
Canyon Reference Lab, Clinical Laboratory. Service 2026-08-04 at independent laboratory (POS 81). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Janet Lopez
- Member ID
- UHC-53522-23
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-402845
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3153
- Coverage period
- 2021-12-01 to present
- Deductible
- $144.70 of $2,500.006%
- Out-of-pocket maximum
- $2,108.27 of $7,500.0028%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1357873425
- Network
- In network
- Rendering NPI
- 1357873425
- Location
- Charlotte, NC · TIN 61-7753780
- Authorisation / referral
- none / REF491758
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 | $47.00 | $29.14 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $58.00 | $35.96 | — | — | Review |
| Totals | $105.00 | $65.10 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-112014
- 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-044129 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-04: CORE-HMO (HMO), effective 2021-12-01. | |
| Timely filing | Pass | Received 41 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 | Pass | In-network provider Canyon Reference Lab (1357873425). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vital”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Reference Lab2026-08-04 17:12
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-14 05:27
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vital”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.