CLM-2026-020738
Canyon Reference Lab, Clinical Laboratory. Service 2026-03-30 at independent laboratory (POS 81). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Denise Dunn
- Member ID
- UHC-66614-26
- Date of birth
- 1954-05-11
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-405528
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4923
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,885.30 of $3,500.0054%
- Out-of-pocket maximum
- $4,468.11 of $14,000.0032%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 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 | 80061 | Lipid panel | — | 1 | 1 | $82.00 | $36.90 | $36.90 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $36.00 | $16.20 | $16.20 | $0.00 | Paid |
| Totals | $118.00 | $53.10 | $53.10 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-336389
- 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-009332 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-03-30: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 36 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Reference Lab2026-03-30 13:55
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019664 | 2026-06-27 | Meadow Imaging Center | $3,584.00 | Needs review |
| CLM-2026-005488 | 2026-06-18 | Mesa GI Associates | $2,458.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.