Professional claim · CMS-1500 · EDI 837P
CLM-2026-017054
Canyon Reference Lab, Clinical Laboratory. Service 2026-02-27 at independent laboratory (POS 81). Received 2026-04-12.
Approved
Billed
$141.00
3 lines
Allowed
$87.42
contract rate applied
Plan pays
$0.00
approved
Member owes
$87.42
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jerry Romero
- Member ID
- UHC-98312-99
- Date of birth
- 1964-03-24
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-412847
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5539
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,569.72 of $3,500.0073%
- Out-of-pocket maximum
- $3,838.54 of $10,500.0037%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 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 / REF156223
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 | 87086 | Urine culture | — | 1 | 1 | $54.00 | $33.48 | $33.48 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $42.00 | $26.04 | $26.04 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $45.00 | $27.90 | $27.90 | $0.00 | Paid |
| Totals | $141.00 | $87.42 | $87.42 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-703575
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023099 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-27: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 44 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 (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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Reference Lab2026-02-27 12:30
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$141.00
Plan discount
$53.58
contracted rate
Plan paid
$0.00
You may owe
$87.42
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016075 | 2026-06-03 | Evergreen Orthopedic Specialists | $5,950.00 | Approved |
| CLM-2026-013531 | 2026-06-03 | Desert Regional Medical Center | $951.00 | Needs review |
| CLM-2026-017055 | 2026-02-27 | Canyon Reference Lab | $141.00 | Needs review |
| CLM-2026-033335 | 2026-03-24 | Canyon Heart Institute | $703.00 | Denied |
| CLM-2026-002754 | 2025-10-06 | Canyon Reference Lab | $167.00 | Denied |
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.