CLM-2026-001681
Desert Clinical Laboratories, Clinical Laboratory. Service 2026-01-26 at independent laboratory (POS 81). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Sharon Sims
- Member ID
- none on golden record
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422802
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Desert Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9068366761
- Network
- In network
- Rendering NPI
- 9068366761
- Location
- Houston, TX · TIN 28-8573609
- 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 | 80061 | Lipid panel | — | 1 | 1 | $71.00 | $44.02 | — | — | PendedIDQ |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $53.00 | $32.86 | — | — | PendedIDQ |
| 3 | 87086 | Urine culture | — | 1 | 2 | $34.00 | $21.08 | — | — | PendedIDQ |
| Totals | $158.00 | $97.96 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-294480
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002975; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 26 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 Desert Clinical Laboratories (9068366761). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for urinary tract infection, site not specified. Plan discussed, medications rec”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Clinical Laboratories2026-01-26 16:12
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-21 04:33
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-21 09:39
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002975; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Follow-up for urinary tract infection, site not specified. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.