CLM-2026-030242
Canyon Clinical Laboratories, Clinical Laboratory. Service 2026-01-05 at independent laboratory (POS 81). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Seaan Price
- Member ID
- UHC-80429-86
- Date of birth
- 1983-08-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411749
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6237
- Coverage period
- 2025-02-01 to present
- Deductible
- $2,195.40 of $2,500.0088%
- Out-of-pocket maximum
- $2,699.46 of $10,000.0027%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1502740933
- Network
- In network
- Rendering NPI
- 1502740933
- Location
- Austin, TX · TIN 73-8355660
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $39.00 | $24.18 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $60.00 | $37.20 | — | — | DeniedCO29 |
| Totals | $99.00 | $61.38 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-642429
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022827 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-05: CORE-HMO (HMO), effective 2025-02-01. | |
| Timely filing | Fail | CO29 | Received 145 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Clinical Laboratories (1502740933). | |
| 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 Clinical Laboratories2026-01-05 11:49
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-30 02:34
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 145 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024245 | 2026-03-09 | Valley Heart Institute | $445.00 | 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
Received after the timely-filing limit.