CLM-2026-000750
Lakeside Reference Lab, Clinical Laboratory. Service 2025-11-13 at independent laboratory (POS 81). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Gloria Jenkins
- Member ID
- UHC-11177-62
- Date of birth
- 1951-12-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414012
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1232
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,106.27 of $1,500.0074%
- Out-of-pocket maximum
- $1,104.29 of $3,000.0037%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 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 / 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $51.00 | $31.62 | — | — | DeniedCO29 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 2 | $64.00 | $39.68 | — | — | DeniedCO29 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $79.00 | $48.98 | — | — | DeniedCO29 |
| Totals | $194.00 | $120.28 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-594866
- 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-003587 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-13: - (PPO), effective 2024-09-01. | |
| Timely filing | Fail | CO29 | Received 117 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 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 Lab2025-11-13 10:15
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-10 03:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
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 117 days after the last date of service (limit 90).
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
Received after the timely-filing limit.