CLM-2026-028070
Canyon Reference Lab, Clinical Laboratory. Service 2026-09-09 at independent laboratory (POS 81). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Roy Wright
- Member ID
- none on golden record
- Date of birth
- 2005-01-27
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413534
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-1669
- Coverage period
- 2025-12-01 to present
- Deductible
- $337.04 of $2,500.0013%
- Out-of-pocket maximum
- $2,395.53 of $10,000.0024%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 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 | 80061 | Lipid panel | — | 1 | 1 | $71.00 | $31.95 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $45.00 | $20.25 | — | — | Review |
| Totals | $116.00 | $52.20 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-203989
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-045140 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-09-09: MEDICARE-ADV-B (MA), effective 2025-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-028069; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 Lab2026-09-09 10:16
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-10-08 06:20
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-028069.pdf1 page
Provider cover letter requesting replacement of CLM-2026-028069.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Eligibility: Active on 2026-09-09: MEDICARE-ADV-B (MA), effective 2025-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. Replacement claim: Frequency code 7 replaces CLM-2026-028069; the original must be voided when this adjudicates. 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-2026-028069 | 2026-09-09 | Canyon Reference Lab | $116.00 | Approved |
| CLM-2026-017572 | 2026-04-22 | Lakeside Physical Therapy | $197.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.