CLM-2026-030153
Canyon Reference Lab, Clinical Laboratory. Service 2026-01-11 at independent laboratory (POS 81). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Nicholas Little
- Member ID
- UHC-39095-13
- Date of birth
- 1996-03-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-411039
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0792
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,001.76 of $1,500.0067%
- Out-of-pocket maximum
- $432.87 of $4,500.0010%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2842605471
- Network
- In network
- Rendering NPI
- 2842605471
- Location
- Denver, CO · TIN 30-7666954
- 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 | 59 | 1 | 1 | $75.00 | $46.50 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | 59 | 1 | 1,2 | $72.00 | $44.64 | — | — | Review |
| Totals | $147.00 | $91.14 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-672223
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015104 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-11: CORE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 42 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 | Pass | In-network provider Canyon Reference Lab (2842605471). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Lab2026-01-11 11:09
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-02-22 01:54
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-22 16:52
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-672223.pdf5 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Bundled code pair; modifier 59 not supported by the operative note.