CLM-2026-017055
Canyon Reference Lab, Clinical Laboratory. Service 2026-02-27 at independent laboratory (POS 81). Received 2026-04-28.
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 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $42.00 | $26.04 | — | — | Review |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $45.00 | $27.90 | — | — | Review |
| Totals | $141.00 | $87.42 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-166368
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 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 60 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-017054; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 Lab2026-02-27 11:51
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-04-28 03:17
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-28 13:46
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-017054.pdf1 page
Provider cover letter requesting replacement of CLM-2026-017054.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-017054; the original must be voided when this adjudicates.
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-2026-017054 | 2026-02-27 | Canyon Reference Lab | $141.00 | Approved |
| 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
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
Replacement claim supersedes the original.