CLM-2026-003849
Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-06-30 at independent laboratory (POS 81). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Austin Park
- Member ID
- UHC-57701-65
- Date of birth
- 1987-07-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-411150
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0393
- Coverage period
- 2025-10-01 to present
- Deductible
- $169.39 of $1,000.0017%
- Out-of-pocket maximum
- $1,077.22 of $4,000.0027%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4514050481
- Network
- In network
- Rendering NPI
- 4514050481
- Location
- Tempe, AZ · TIN 12-2226671
- 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 | 87086 | Urine culture | — | 1 | 1 | $62.00 | $38.44 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $74.00 | $45.88 | — | — | DeniedCO18 |
| Totals | $136.00 | $84.32 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-192301
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037769 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-30: MEDICARE-ADV-B (MA), effective 2025-10-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003848: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Clinical Laboratories (4514050481). | |
| 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: Riverside Clinical Laboratories2026-06-30 13:47
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-07-21 03:03
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003848: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003848 | 2026-06-30 | Riverside Clinical Laboratories | $136.00 | Approved |
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
Exact duplicate of an earlier submission.