CLM-2026-005209
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-07-09 at independent laboratory (POS 81). Received 2026-07-29.
Member
Resolved through the identity graph
- Member
- Tyler Vargas
- Member ID
- UHC-54913-54
- Date of birth
- 1980-01-13
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-418765
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2525
- Coverage period
- 2025-04-01 to 2026-01-20
- Deductible
- $820.51 of $1,000.0082%
- Out-of-pocket maximum
- $1,793.58 of $4,000.0045%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3912329836
- Network
- In network
- Rendering NPI
- 3912329836
- Location
- Nashville, TN · TIN 38-7470413
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $48.00 | $29.76 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $45.00 | $27.90 | — | — | DeniedCO27 |
| Totals | $93.00 | $57.66 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-157031
- 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-013478 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-09 is after coverage terminated on 2026-01-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 Summit Clinical Laboratories (3912329836). | |
| 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: Summit Clinical Laboratories2026-07-09 18:20
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-29 05:42
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-29 14:07
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-09 is after coverage terminated on 2026-01-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004526 | 2026-05-13 | Desert Internal Medicine Associates | $333.00 | Denied |
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.