CLM-2026-002011
Desert Reference Lab, Clinical Laboratory. Service 2026-09-10 at independent laboratory (POS 81). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Larry Jones
- Member ID
- UHC-94064-39
- Date of birth
- 1950-06-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-408323
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9933
- Coverage period
- 2021-02-01 to 2026-01-23
- Deductible
- $1,815.26 of $3,500.0052%
- Out-of-pocket maximum
- $2,261.00 of $14,000.0016%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 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 / 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 | $61.00 | $27.45 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $42.00 | $18.90 | — | — | DeniedCO27 |
| Totals | $103.00 | $46.35 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-585657
- 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 | Pass | Attached to MBR-003991 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-10 is after coverage terminated on 2026-01-23. Expenses incurred after coverage terminated |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Lab2026-09-10 14:16
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-30 05:43
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-30 08:23
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-10 is after coverage terminated on 2026-01-23. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016145 | 2026-08-31 | Unity Primary Care Associates | $500.00 | Denied |
| CLM-2026-034137 | 2026-01-20 | Valley Reference Lab | $156.00 | 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
Service after coverage termination.