CLM-2026-034277
Canyon Reference Lab, Clinical Laboratory. Service 2026-07-22 at independent laboratory (POS 81). Received 2026-08-25.
Member
Resolved through the identity graph
- Member
- Lisa Berry
- Member ID
- UHC-31792-15
- Date of birth
- 1993-11-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407800
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-4916
- Coverage period
- 2023-02-01 to 2026-02-01
- Deductible
- $430.43 of $500.0086%
- Out-of-pocket maximum
- $185.29 of $1,000.0019%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1357873425
- Network
- In network
- Rendering NPI
- 1357873425
- Location
- Charlotte, NC · TIN 61-7753780
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $46.00 | $28.52 | — | — | DeniedCO27 |
| 3 | 80061 | Lipid panel | — | 1 | 1,2 | $38.00 | $23.56 | — | — | DeniedCO27 |
| Totals | $133.00 | $82.46 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-879987
- 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-028476 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-02-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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 (1357873425). | |
| 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 Lab2026-07-22 13:50
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-25 02:04
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-25 10:42
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-02-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020921 | 2026-04-14 | Harbor Bone and Joint Center | $490.00 | Denied |
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
Service after coverage termination.