CLM-2026-002594
Desert Clinical Laboratories, Clinical Laboratory. Service 2026-02-19 at independent laboratory (POS 81). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Jonathan Pierce
- Member ID
- UHC-45594-56
- Date of birth
- 1943-09-18
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-413285
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1156
- Coverage period
- 2023-09-01 to present
- Deductible
- $823.05 of $1,500.0055%
- Out-of-pocket maximum
- $629.87 of $4,500.0014%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
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 / REF563861
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 | $68.00 | $42.16 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $56.00 | $34.72 | — | — | DeniedCO29 |
| 3 | 80061 | Lipid panel | — | 1 | 2 | $35.00 | $21.70 | — | — | DeniedCO29 |
| Totals | $159.00 | $98.58 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-454634
- 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-017419 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-19: NAVIGATE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Fail | CO29 | Received 217 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 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Clinical Laboratories2026-02-19 14:25
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-09-24 03:51
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 217 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021122 | 2026-06-20 | Lakeside Medical Group | $251.00 | Denied |
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.