CLM-2026-028120
Canyon Reference Lab, Clinical Laboratory. Service 2026-09-11 at independent laboratory (POS 81). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Debra Warren
- Member ID
- none on golden record
- Date of birth
- 1972-08-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-420687
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-9198
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,761.16 of $3,500.0050%
- Out-of-pocket maximum
- $6,919.15 of $14,000.0049%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $59.00 | $26.55 | — | — | DeniedCO204 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $62.00 | $27.90 | — | — | DeniedCO204 |
| Totals | $121.00 | $54.45 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-557156
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003144; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-09-11: SELECT-EPO (EPO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 10 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 9852346359 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 Lab2026-09-11 17:30
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-09-21 05:08
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-003144; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-11: SELECT-EPO (EPO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 9852346359 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.