CLM-2026-016107
Canyon Clinical Laboratories, Clinical Laboratory. Service 2026-05-15 at independent laboratory (POS 81). Received 2026-09-20.
Member
Resolved through the identity graph
- Member
- Ronald Reid
- Member ID
- UHC-15374-37
- Date of birth
- 1978-09-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414825
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9974
- Coverage period
- 2023-12-01 to present
- Deductible
- $781.59 of $1,000.0078%
- Out-of-pocket maximum
- $927.51 of $2,000.0046%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1502740933
- Network
- In network
- Rendering NPI
- 1502740933
- Location
- Austin, TX · TIN 73-8355660
- Authorisation / referral
- none / REF986906
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 | $76.00 | $47.12 | — | — | DeniedCO29 |
| Totals | $76.00 | $47.12 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-327598
- 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-021238 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-15: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Fail | CO29 | Received 128 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 Clinical Laboratories (1502740933). | |
| 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 Clinical Laboratories2026-05-15 17:02
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-09-20 01:34
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-20 11:21
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 128 days after the last date of service (limit 90).
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
Received after the timely-filing limit.