CLM-2026-033816
Canyon Reference Lab, Clinical Laboratory. Service 2026-01-19 at independent laboratory (POS 81). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Danielle Kelley
- Member ID
- UHC-50091-64
- Date of birth
- 2003-01-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415039
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6344
- Coverage period
- 2023-05-01 to present
- Deductible
- $75.15 of $1,000.008%
- Out-of-pocket maximum
- $1,253.01 of $3,000.0042%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 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 / REF342180
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 | $67.00 | $30.15 | — | — | DeniedCO204 |
| 2 | 85025 | Complete blood count with differential | 25 | 1 | 1,2 | $62.00 | $27.90 | — | — | DeniedCO204 |
| 3 | 87086 | Urine culture | — | 1 | 1 | $38.00 | $17.10 | — | — | DeniedCO204 |
| Totals | $167.00 | $75.15 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-938463
- 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-010989 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-19: NAVIGATE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 32 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 8227331807 is out of network and the HMO 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 Lab2026-01-19 09:06
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-02-20 01:10
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-20 15:06
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 8227331807 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012019 | 2026-01-29 | Pinecrest Primary Care Associates | $520.00 | Denied |
| CLM-2026-012018 | 2026-01-29 | Pinecrest Primary Care Associates | $520.00 | 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
No out-of-network benefit on this plan.