CLM-2026-002130
Evergreen Clinical Laboratories, Clinical Laboratory. Service 2025-11-07 at independent laboratory (POS 81). Received 2026-04-03.
Member
Resolved through the identity graph
- Member
- Heather Brooks
- Member ID
- UHC-62227-54
- Date of birth
- 1978-07-08
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-424381
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7936
- Coverage period
- 2024-08-01 to present
- Deductible
- $888.80 of $1,500.0059%
- Out-of-pocket maximum
- $1,463.68 of $4,500.0033%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5984537261
- Network
- In network
- Rendering NPI
- 5984537261
- Location
- Mesa, AZ · TIN 92-1302766
- Authorisation / referral
- none / REF617795
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $75.00 | $46.50 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $55.00 | $34.10 | — | — | DeniedCO29 |
| Totals | $130.00 | $80.60 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-200241
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011977 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-11-07: NAVIGATE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Fail | CO29 | Received 147 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 Evergreen Clinical Laboratories (5984537261). | |
| 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: Evergreen Clinical Laboratories2025-11-07 15:53
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-03 01:53
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 engineDenied2026-10-21 13:43Timely filing: Received 147 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.