Professional claim · CMS-1500 · EDI 837P
CLM-2026-004980
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-01-14 at independent laboratory (POS 81). Received 2026-02-05.
DeniedOut of network
Billed
$91.00
2 lines
Allowed
$40.95
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Eugene Nichols
- Member ID
- UHC-77317-26
- Date of birth
- 1980-03-11
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-424571
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4279
- Coverage period
- 2023-12-01 to 2026-01-10
- Deductible
- $1,986.40 of $2,500.0079%
- Out-of-pocket maximum
- $330.96 of $7,500.004%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2122435433
- Network
- Out of network
- Rendering NPI
- 2122435433
- Location
- Los Angeles, CA · TIN 12-4722693
- Authorisation / referral
- none / REF627032
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 | $49.00 | $22.05 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $42.00 | $18.90 | — | — | DeniedCO27 |
| Totals | $91.00 | $40.95 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-325893
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002529 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-14 is after coverage terminated on 2026-01-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 | Fail | CO204 | Billing provider 2122435433 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Clinical Laboratories2026-01-14 14:54
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-02-05 03:03
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-05 09:17
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-14 is after coverage terminated on 2026-01-10. Provider network: Billing provider 2122435433 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017962 | 2026-05-20 | Unity Digestive Health Center | $4,722.00 | Denied |
| CLM-2026-000160 | 2025-11-27 | Pinecrest Diagnostic Imaging | $2,724.00 | Denied |
| CLM-2026-000159 | 2025-11-27 | Pinecrest Diagnostic Imaging | $2,724.00 | Approved |
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.