CLM-2026-003926
Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-04-18 at independent laboratory (POS 81). Received 2026-05-11.
Member
Resolved through the identity graph
- Member
- Joseph Wheeler
- Member ID
- UHC-73218-61
- Date of birth
- 1991-05-12
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-417720
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3811
- Coverage period
- 2025-03-01 to present
- Deductible
- $383.64 of $1,000.0038%
- Out-of-pocket maximum
- $576.92 of $2,000.0029%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 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 | 80061 | Lipid panel | — | 1 | 1 | $44.00 | $27.28 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $56.00 | $34.72 | — | — | DeniedCO18 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $87.00 | $53.94 | — | — | DeniedCO18 |
| Totals | $187.00 | $115.94 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-530149
- 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-027694 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-18: UNKNOWN (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003925: 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 Laboratories2026-04-18 12:48
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-11 04:14
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-003925: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023266 | 2026-08-24 | Mesa Cardiovascular Associates | $602.00 | Approved |
| CLM-2026-000405 | 2026-08-17 | Mesa GI Associates | $3,389.00 | Approved |
| CLM-2026-001525 | 2026-05-07 | Canyon Community Hospital | $900.00 | Approved |
| CLM-2026-003925 | 2026-04-18 | Riverside Clinical Laboratories | $187.00 | 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.