CLM-2026-006216
Pinecrest Reference Lab, Clinical Laboratory. Service 2025-09-14 at independent laboratory (POS 81). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Karen Powell
- Member ID
- UHC-06715-98
- Date of birth
- 1988-04-09
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-426949
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1921
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,843.67 of $2,500.0074%
- Out-of-pocket maximum
- $1,145.16 of $7,500.0015%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4399070182
- Network
- In network
- Rendering NPI
- 4399070182
- Location
- Houston, TX · TIN 93-0870375
- 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 | $79.00 | $48.98 | — | — | DeniedCO29 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $52.00 | $32.24 | — | — | DeniedCO29 |
| Totals | $131.00 | $81.22 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-192045
- 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-006911 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-14: MEDICARE-ADV-A (MA), effective 2022-02-01. | |
| Timely filing | Fail | CO29 | Received 131 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Reference Lab (4399070182). | |
| 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: Pinecrest Reference Lab2025-09-14 14:04
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-23 00:52
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 131 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019859 | 2026-04-15 | Pinecrest Diagnostic Imaging | $520.00 | Approved |
| CLM-2026-001877 | 2026-02-13 | Unity Reference Lab | $102.00 | Denied |
| CLM-2026-001876 | 2026-02-13 | Unity Reference Lab | $102.00 | 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
Received after the timely-filing limit.