CLM-2026-024616
Canyon Reference Lab, Clinical Laboratory. Service 2026-07-02 at independent laboratory (POS 81). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Timothy Walsh
- Member ID
- UHC-68781-22
- Date of birth
- 1990-01-06
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-412441
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3761
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,255.90 of $3,500.0036%
- Out-of-pocket maximum
- $4,400.50 of $10,500.0042%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8227331807
- Network
- Out of network
- Rendering NPI
- 8227331807
- Location
- Los Angeles, CA · TIN 88-1576930
- 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 | $82.00 | $36.90 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $78.00 | $35.10 | — | — | DeniedCO18 |
| Totals | $160.00 | $72.00 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-952876
- 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 | Pass | Attached to MBR-008743 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-02: CHOICE-PLUS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024615: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Lab2026-07-02 09:47
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-13 01:04
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-024615: same member, date of service, procedures and billing provider. 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024615 | 2026-07-02 | Canyon Reference Lab | $160.00 | Approved |
| CLM-2026-004625 | 2026-03-09 | Northgate Counseling Center | $261.00 | 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.