CLM-2026-033589
Canyon Reference Lab, Clinical Laboratory. Service 2026-08-01 at independent laboratory (POS 81). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Alan Hoffan
- Member ID
- UHC-60711-43
- Date of birth
- 1971-07-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415001
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7087
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,102.38 of $1,500.0073%
- Out-of-pocket maximum
- $2,239.90 of $4,500.0050%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 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 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1 | $65.00 | $40.30 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | 59 | 1 | 1,2 | $62.00 | $38.44 | — | — | Review |
| Totals | $127.00 | $78.74 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-972840
- 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-041196 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-01: MEDICARE-ADV-B (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 17 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 Lab2026-08-01 14:08
Patient seen for urinary tract infection, site not specified. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-08-18 04:29
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-18 16:38
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-972840.pdf16 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.