CLM-2026-019010
Canyon Reference Lab, Clinical Laboratory. Service 2026-01-24 at independent laboratory (POS 81). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Christine Wallace
- Member ID
- UHC-56875-41
- Date of birth
- 1962-08-25
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-431706
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1427
- Coverage period
- 2022-04-01 to present
- Deductible
- $700.24 of $1,000.0070%
- Out-of-pocket maximum
- $214.14 of $4,000.005%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 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 / 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $38.00 | $23.56 | — | — | DeniedCO18 |
| Totals | $38.00 | $23.56 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-952135
- 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-000404 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-24: OPTIONS-PPO (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-019009: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 | 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 Lab2026-01-24 15:59
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-17 01:23
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-17 11:50
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-019009: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009549 | 2026-10-03 | Lakeside Skin Care Associates | $162.00 | Approved |
| CLM-2026-004105 | 2026-09-09 | Lakeside Bone and Joint Center | $35,290.00 | Needs review |
| CLM-2026-019009 | 2026-01-24 | Canyon Reference Lab | $38.00 | Approved |
| CLM-2026-003011 | 2025-12-05 | Meadow Physical Therapy | $277.00 | Approved |
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
Exact duplicate of an earlier submission.