CLM-2026-002438
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-02-28 at independent laboratory (POS 81). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Raymond Wood
- Member ID
- UHC-43430-18
- Date of birth
- 1977-12-17
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404115
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5840
- Coverage period
- 2023-06-01 to present
- Deductible
- $508.78 of $1,000.0051%
- Out-of-pocket maximum
- $1,098.16 of $3,000.0037%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2382593988
- Network
- In network
- Rendering NPI
- 2382593988
- Location
- Atlanta, GA · TIN 17-8035936
- 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 | $50.00 | $31.00 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $76.00 | $47.12 | — | — | Review |
| Totals | $126.00 | $78.12 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-859339
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014993 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-28: MEDICARE-ADV-B (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-002437; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Clinical Laboratories (2382593988). | |
| 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: Mesa Clinical Laboratories2026-02-28 10:45
Patient seen for urinary tract infection, site not specified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-04-05 03:03
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-05 08:05
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-002437.pdf1 page
Provider cover letter requesting replacement of CLM-2026-002437.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-002437; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022451 | 2026-06-12 | Meadow Family Practice | $202.00 | Approved |
| CLM-2026-001672 | 2026-04-17 | Unity Reference Lab | $60.00 | Approved |
| CLM-2026-021662 | 2026-03-30 | Harbor Primary Care Associates | $187.00 | Approved |
| CLM-2026-002437 | 2026-02-28 | Mesa Clinical Laboratories | $126.00 | Approved |
| CLM-2026-000683 | 2026-01-24 | Lakeside Physical Therapy | $640.00 | Approved |
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
Replacement claim supersedes the original.