CLM-2026-000295
Lakeside Reference Lab, Clinical Laboratory. Service 2026-01-09 at independent laboratory (POS 81). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Susan Padilla
- Member ID
- UHC-73638-75
- Date of birth
- 1981-03-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407405
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4147
- Coverage period
- 2021-12-01 to 2026-01-08
- Deductible
- $874.99 of $1,500.0058%
- Out-of-pocket maximum
- $109.68 of $4,500.002%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7601465819
- Network
- In network
- Rendering NPI
- 7601465819
- Location
- Charlotte, NC · TIN 32-5251661
- Authorisation / referral
- none / REF576060
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 | $44.00 | $27.28 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $46.00 | $28.52 | — | — | DeniedCO27 |
| Totals | $90.00 | $55.80 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-363784
- 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-009656 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-09 is after coverage terminated on 2026-01-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 Lakeside Reference Lab (7601465819). | |
| 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: Lakeside Reference Lab2026-01-09 15:35
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-02-02 02:02
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-02 16:28
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-09 is after coverage terminated on 2026-01-08.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017264 | 2026-05-22 | Canyon Diagnostic Imaging | $2,067.00 | Denied |
| CLM-2026-032299 | 2025-12-25 | Desert Primary Care Associates | $3,561.00 | Needs review |
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.