Claims workbench/CLM-2026-003792
Professional claim · CMS-1500 · EDI 837P

CLM-2026-003792

Desert Reference Lab, Clinical Laboratory. Service 2026-05-19 at independent laboratory (POS 81). Received 2026-06-08.

Denied
Billed
$138.00
2 lines
Allowed
$85.56
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Mariana Valdez
Member ID
UHC-75813-69
Date of birth
1982-11-22
Identity
Verified6 records, confidence 0.86
Claim record
CLMCLM-415391
Relationship
Child, Dallas, TX

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-A MA group GRP-8742
Coverage period
2025-05-01 to present
Deductible
$1,291.91 of $1,500.0086%
Out-of-pocket maximum
$806.62 of $3,000.0027%
Copays
office $30.00, specialist $40.00, emergency $150.00
Physical therapy visits
5 of 20 used

Provider

Billing and rendering

Billing provider
Desert Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI
5002077423
Network
In network
Rendering NPI
5002077423
Location
Nashville, TN · TIN 21-2185658
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
183036Hemoglobin A1c—11$67.00$41.54——DeniedCO18
280061Lipid panel—11,2$71.00$44.02——DeniedCO18
Totals$138.00$85.56——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
  • 2. N39.0 Urinary tract infection, site not specified
Claim header
Patient account
PA-626055
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

CheckResultCodeDetail
Member identityPassAttached to MBR-009951 (verified, link confidence 0.86).
EligibilityPassActive on 2026-05-19: MEDICARE-ADV-A (MA), effective 2025-05-01.
Timely filingPassReceived 20 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-003791: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Reference Lab (5002077423).
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: Desert Reference Lab2026-05-19 16:53

    Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.

  • SystemSystem: Claims system2026-06-08 05:08

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

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
    Duplicate check: Exact duplicate of CLM-2026-003791: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0016492026-07-01Lakeside Imaging Center$385.00Approved
CLM-2026-0037912026-05-19Desert Reference Lab$138.00Approved

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity