CLM-2026-026246
Canyon Reference Lab, Clinical Laboratory. Service 2026-03-28 at independent laboratory (POS 81). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Anna Hall
- Member ID
- UHC-10415-23
- Date of birth
- 2001-04-04
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-409188
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8945
- Coverage period
- 2023-03-01 to 2026-03-09
- Deductible
- $276.42 of $1,000.0028%
- Out-of-pocket maximum
- $1,929.59 of $4,000.0048%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $48.00 | $21.60 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $61.00 | $27.45 | — | — | DeniedCO27 |
| Totals | $109.00 | $49.05 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-452211
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027789 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-28 is after coverage terminated on 2026-03-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 | Fail | CO204 | Billing provider 8227331807 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Lab2026-03-28 16:43
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-12 00:31
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-12 14:49
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-28 is after coverage terminated on 2026-03-09. Provider network: Billing provider 8227331807 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014379 | 2026-04-21 | Desert Reference Lab | $118.00 | Denied |
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
Service after coverage termination.