Professional claim · CMS-1500 · EDI 837P
CLM-2026-018742
Canyon Reference Lab, Clinical Laboratory. Service 2026-05-04 at independent laboratory (POS 81). Received 2026-05-26.
PendedOut of network
Billed
$199.00
3 lines
Allowed
$89.55
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
CO16
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2806
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,509.02 of $2,500.0060%
- Out-of-pocket maximum
- $1,727.53 of $7,500.0023%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 9852346359
- Network
- Out of network
- Rendering NPI
- 9852346359
- Location
- Houston, TX · TIN 65-3102766
- 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 | $66.00 | $29.70 | — | — | PendedCO16 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $70.00 | $31.50 | — | — | PendedCO16 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1 | $63.00 | $28.35 | — | — | PendedCO16 |
| Totals | $199.00 | $89.55 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
Claim header
- Patient account
- PA-480879
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-05-04: MEDICARE-ADV-B (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 22 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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Reference Lab2026-05-04 14:16
Patient seen for urinary tract infection, site not specified.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. 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
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.