Claims workbench/CLM-2026-005712

Professional claim · CMS-1500 · EDI 837P

CLM-2026-005712

Desert Clinical Laboratories, Clinical Laboratory. Service 2026-08-06 at independent laboratory (POS 81). Received 2026-09-23.

Denied

Billed

$194.00

3 lines

Allowed

$120.28

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Adam Vega
Member ID: UHC-59055-13
Date of birth: 1992-02-01
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-425769
Relationship: Spouse, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3911
Coverage period: 2024-03-01 to present
Deductible: $158.59 of $2,500.006%
Out-of-pocket maximum: $1,385.71 of $10,000.0014%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Desert Clinical Laboratories
Clinical Laboratory · taxonomy 291U00000X
NPI: 9068366761
Network: In network
Rendering NPI: 9068366761
Location: Houston, TX · TIN 28-8573609
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	$75.00	$46.50	—	—	DeniedCO18
2	87086	Urine culture	—	1	1,2	$53.00	$32.86	—	—	DeniedCO18
3	83036	Hemoglobin A1c	—	1	2	$66.00	$40.92	—	—	DeniedCO18
Totals						$194.00	$120.28	—	—

Diagnoses (ICD-10-CM)

1. N39.0 Urinary tract infection, site not specifiedprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-183052
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-027921 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-06: OPTIONS-PPO (PPO), effective 2024-03-01.
Timely filing	Pass		Received 48 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-005711: 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 Desert Clinical Laboratories (9068366761).
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: Desert Clinical Laboratories2026-08-06 15:55
Patient seen for urinary tract infection, site not specified.
SystemSystem: Claims system2026-09-23 04:55
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-005711: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023742	2026-09-16	Summit Regional Medical Center	$2,954.00	Needs review
CLM-2026-005711	2026-08-06	Desert Clinical Laboratories	$194.00	Approved
CLM-2026-000009	2026-07-27	Lakeside Physical Therapy	$266.00	Approved
CLM-2026-017511	2026-05-08	Mesa Medical Group	$223.00	Approved
CLM-2026-026554	2026-04-12	Sunrise Digestive Health Center	$4,959.00	Needs review

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity