CLM-2026-003749
Pinecrest Reference Lab, Clinical Laboratory. Service 2026-01-24 at independent laboratory (POS 81). Received 2026-02-24.
Member
Resolved through the identity graph
- Member
- Kelly Carroll
- Member ID
- none on golden record
- Date of birth
- 1991-12-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-403818
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-1671
- Coverage period
- 2023-02-01 to 2026-01-03
- Deductible
- $1,746.87 of $3,500.0050%
- Out-of-pocket maximum
- $1,389.68 of $7,000.0020%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4399070182
- Network
- In network
- Rendering NPI
- 4399070182
- Location
- Houston, TX · TIN 93-0870375
- 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 | $41.00 | $25.42 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $70.00 | $43.40 | — | — | DeniedCO27 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $70.00 | $43.40 | — | — | DeniedCO27 |
| Totals | $181.00 | $112.22 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-399949
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003063; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-01-24 is after coverage terminated on 2026-01-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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 | Pass | In-network provider Pinecrest Reference Lab (4399070182). | |
| 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: Pinecrest Reference Lab2026-01-24 09:52
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-24 00:00
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-24 12:40
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-003063; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-01-24 is after coverage terminated on 2026-01-03.
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
Service after coverage termination.