CLM-2026-000550
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2025-06-16 at independent laboratory (POS 81). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Carolyn Campbell
- Member ID
- UHC-91732-23
- Date of birth
- 1950-02-15
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-417630
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9263
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,288.25 of $1,500.0086%
- Out-of-pocket maximum
- $524.10 of $3,000.0017%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4658545775
- Network
- In network
- Rendering NPI
- 4658545775
- Location
- Nashville, TN · TIN 46-3944413
- 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 | — | 1 | 1 | $46.00 | $28.52 | — | — | DeniedCO29 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $48.00 | $29.76 | — | — | DeniedCO29 |
| Totals | $94.00 | $58.28 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-474482
- 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-006674 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-06-16: MEDICARE-ADV-A (MA), effective 2022-06-01. | |
| Timely filing | Fail | CO29 | Received 220 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Clinical Laboratories (4658545775). | |
| 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 Clinical Laboratories2025-06-16 17:47
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-22 05:08
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-22 15:23
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 12:44Timely filing: Received 220 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007724 | 2026-06-21 | Desert Primary Care Associates | $280.00 | Approved |
| CLM-2026-026384 | 2026-05-18 | Pinecrest Regional Medical Center | $2,197.00 | 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
Received after the timely-filing limit.