Claims workbench/CLM-2026-003340
Professional claim · CMS-1500 · EDI 837P

CLM-2026-003340

Cornerstone Reference Lab, Clinical Laboratory. Service 2026-08-17 at independent laboratory (POS 81). Received 2026-09-30.

Denied
Billed
$37.00
1 line
Allowed
$22.94
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-3486
Coverage period
2021-03-01 to 2026-08-11
Deductible
$125.14 of $2,500.005%
Out-of-pocket maximum
$2,652.62 of $7,500.0035%
Copays
office $20.00, specialist $40.00, emergency $150.00
Physical therapy visits
17 of 20 used

Provider

Billing and rendering

Billing provider
Cornerstone Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI
4740334576
Network
In network
Rendering NPI
4740334576
Location
Mesa, AZ · TIN 57-0560500
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
185025Complete blood count with differential—11$37.00$22.94——DeniedCO27
Totals$37.00$22.94——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
Patient account
PA-775572
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

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityFailCO27Date of service 2026-08-17 is after coverage terminated on 2026-08-11.
Expenses incurred after coverage terminated
Timely filingPassReceived 44 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Cornerstone Reference Lab (4740334576).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Cornerstone Reference Lab2026-08-17 18:36

    Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-09-30 06:54

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity. Eligibility: Date of service 2026-08-17 is after coverage terminated on 2026-08-11.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue