CLM-2026-000575
Desert Reference Lab, Clinical Laboratory. Service 2026-09-03 at independent laboratory (POS 81). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Kelly Watson
- Member ID
- UHC-78347-04
- Date of birth
- 1986-04-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430429
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5770
- Coverage period
- 2022-05-01 to present
- Deductible
- $184.74 of $3,500.005%
- Out-of-pocket maximum
- $3,260.21 of $10,500.0031%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5138952598
- Network
- Out of network
- Rendering NPI
- 5138952598
- Location
- Mesa, AZ · TIN 53-1049966
- Authorisation / referral
- none / REF810211
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 | $46.00 | $20.70 | — | — | DeniedCO204 |
| Totals | $46.00 | $20.70 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-455514
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001527; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-09-03: NAVIGATE-HMO (HMO), effective 2022-05-01. | |
| Timely filing | Pass | Received 20 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 5138952598 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: Desert Reference Lab2026-09-03 16:33
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-23 03:07
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-001527; payment withheld until the identity is confirmed. Provider network: Billing provider 5138952598 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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.