CLM-2026-005544
Meadow Reference Lab, Clinical Laboratory. Service 2026-06-16 at independent laboratory (POS 81). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Annna Reid
- Member ID
- UHC-32350-43
- Date of birth
- 1965-12-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416304
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5025
- Coverage period
- 2022-06-01 to 2026-04-02
- Deductible
- $182.10 of $1,500.0012%
- Out-of-pocket maximum
- $72.42 of $6,000.001%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4223959956
- Network
- In network
- Rendering NPI
- 4223959956
- Location
- Mesa, AZ · TIN 32-8579975
- 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 | $57.00 | $35.34 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $43.00 | $26.66 | — | — | DeniedCO27 |
| Totals | $100.00 | $62.00 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-148690
- 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-006951 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-16 is after coverage terminated on 2026-04-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 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 Meadow Reference Lab (4223959956). | |
| 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: Meadow Reference Lab2026-06-16 12:28
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-22 01:14
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-22 12:49
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-16 is after coverage terminated on 2026-04-02.
Other claims for this member
Same resolved identity
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.