Professional claim · CMS-1500 · EDI 837P
CLM-2026-001260
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-07-21 at independent laboratory (POS 81). Received 2026-08-19.
Denied
Billed
$124.00
2 lines
Allowed
$76.88
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Harold Espinoza
- Member ID
- UHC-90072-37
- Date of birth
- 1984-09-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-421295
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0792
- Coverage period
- 2023-03-01 to 2026-06-13
- Deductible
- $1,001.07 of $2,500.0040%
- Out-of-pocket maximum
- $571.00 of $5,000.0011%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7665709730
- Network
- In network
- Rendering NPI
- 7665709730
- Location
- Mesa, AZ · TIN 27-4199484
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $54.00 | $33.48 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $70.00 | $43.40 | — | — | DeniedCO27 |
| Totals | $124.00 | $76.88 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-733609
- 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-041972 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-21 is after coverage terminated on 2026-06-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 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 Summit Clinical Laboratories (7665709730). | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Clinical Laboratories2026-07-21 14:45
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-08-19 03:40
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-21 is after coverage terminated on 2026-06-13.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.