CLM-2026-019438
Canyon Clinical Laboratories, Clinical Laboratory. Service 2025-08-21 at independent laboratory (POS 81). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Larry Hunt
- Member ID
- UHC-16807-44
- Date of birth
- 2006-04-09
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-431464
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3341
- Coverage period
- 2023-03-01 to present
- Deductible
- $2,196.77 of $2,500.0088%
- Out-of-pocket maximum
- $2,883.92 of $7,500.0038%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3883165920
- Network
- In network
- Rendering NPI
- 3883165920
- Location
- Charlotte, NC · TIN 14-6212435
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $87.00 | $53.94 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $50.00 | $31.00 | — | — | DeniedCO29 |
| Totals | $137.00 | $84.94 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-443851
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018467 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-08-21: MEDICARE-ADV-A (MA), effective 2023-03-01. | |
| Timely filing | Fail | CO29 | Received 200 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 (3883165920). | |
| 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 Laboratories2025-08-21 18:44
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-09 05:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-09 14:54
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 engineDenied2026-10-22 12:44Timely filing: Received 200 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.