CLM-2026-006103
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-02-07 at independent laboratory (POS 81). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Gary Maldonado
- Member ID
- UHC-81287-58
- Date of birth
- 1978-10-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412259
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group -
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,949.09 of $3,500.0056%
- Out-of-pocket maximum
- $763.07 of $10,500.007%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5775545838
- Network
- In network
- Rendering NPI
- 5775545838
- Location
- Miami, FL · TIN 91-7135882
- 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 | 87086 | Urine culture | — | 1 | 1 | $69.00 | $42.78 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $65.00 | $40.30 | — | — | Review |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 2 | $63.00 | $39.06 | — | — | Review |
| Totals | $197.00 | $122.14 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-764677
- 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-014463 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-07: MEDICARE-ADV-A (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 13 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 Clinical Laboratories (5775545838). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Clinical Laboratories2026-02-07 11:45
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-20 05:23
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-20 12:25
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.