CLM-2026-006431
Desert Reference Lab, Clinical Laboratory. Service 2025-10-28 at independent laboratory (POS 81). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Maria Dixon
- Member ID
- UHC-30547-99
- Date of birth
- 1997-08-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427525
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-9396
- Coverage period
- 2022-03-01 to present
- Deductible
- $539.74 of $1,500.0036%
- Out-of-pocket maximum
- $1,821.23 of $4,500.0040%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5002077423
- Network
- In network
- Rendering NPI
- 5002077423
- Location
- Nashville, TN · TIN 21-2185658
- 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 | $63.00 | $39.06 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $88.00 | $54.56 | — | — | DeniedCO29 |
| Totals | $151.00 | $93.62 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-288527
- 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-009977 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-28: - (PPO), effective 2022-03-01. | |
| Timely filing | Fail | CO29 | Received 98 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 Desert Reference Lab (5002077423). | |
| 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: Desert Reference Lab2025-10-28 10:39
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-03 02:53
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-03 17:04
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 engineDenied2026-10-22 12:44Timely filing: Received 98 days after the last date of service (limit 90).
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
Received after the timely-filing limit.