CLM-2026-005327
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-01-02 at independent laboratory (POS 81). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Ahmed Hernandez
- Member ID
- UHC-21736-01
- Date of birth
- 1942-04-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415425
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4600
- Coverage period
- 2025-01-01 to present
- Deductible
- $808.76 of $1,000.0081%
- Out-of-pocket maximum
- $480.79 of $4,000.0012%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 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 / 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $59.00 | $26.55 | — | — | DeniedCO204 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $44.00 | $19.80 | — | — | DeniedCO204 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $55.00 | $24.75 | — | — | DeniedCO204 |
| Totals | $158.00 | $71.10 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-173956
- 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-003163 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-02: SELECT-EPO (EPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 8 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 EPO 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Clinical Laboratories2026-01-02 17:57
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-10 02:27
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2122435433 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021141 | 2026-08-20 | Unity Community Hospital | $146.00 | Approved |
| CLM-2026-001054 | 2026-03-01 | Evergreen Primary Care Associates | $316.00 | 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
No out-of-network benefit on this plan.