Professional claim · CMS-1500 · EDI 837P
CLM-2026-034477
Canyon Reference Lab, Clinical Laboratory. Service 2026-05-26 at independent laboratory (POS 81). Received 2026-07-04.
Approved
Billed
$161.00
3 lines
Allowed
$99.82
contract rate applied
Plan pays
$0.00
approved
Member owes
$99.82
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Catherine Hoffman
- Member ID
- UHC-61532-06
- Date of birth
- 1949-01-28
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-400920
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7376
- Coverage period
- 2024-02-01 to present
- Deductible
- $242.50 of $1,500.0016%
- Out-of-pocket maximum
- $1,600.01 of $4,500.0036%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 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 | 87086 | Urine culture | — | 1 | 1 | $32.00 | $19.84 | $19.84 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $69.00 | $42.78 | $42.78 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1,2 | $60.00 | $37.20 | $37.20 | $0.00 | Paid |
| Totals | $161.00 | $99.82 | $99.82 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-532110
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018829 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-26: OPTIONS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 39 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Reference Lab2026-05-26 11:45
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$161.00
Plan discount
$61.18
contracted rate
Plan paid
$0.00
You may owe
$99.82
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016110 | 2026-04-15 | Harbor Bone and Joint Center | $11,665.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.