CLM-2026-006772
Desert Reference Lab, Clinical Laboratory. Service 2026-06-24 at independent laboratory (POS 81). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Sean Evans
- Member ID
- UHC-66436-57
- Date of birth
- 1958-08-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400445
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4864
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,290.27 of $2,500.0052%
- Out-of-pocket maximum
- $1,139.82 of $7,500.0015%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5138952598
- Network
- Out of network
- Rendering NPI
- 5138952598
- Location
- Mesa, AZ · TIN 53-1049966
- Authorisation / referral
- none / REF488542
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 | $40.00 | $18.00 | — | — | DeniedCO204 |
| Totals | $40.00 | $18.00 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-235688
- 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-011750 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-24: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 12 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 | Fail | CO204 | Billing provider 5138952598 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Lab2026-06-24 11:18
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-06 01:43
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-06 15:33
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 engineDenied2026-10-21 13:43Provider network: Billing provider 5138952598 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028951 | 2026-09-01 | Summit Diagnostic Imaging | $3,282.00 | Needs review |
| CLM-2026-024506 | 2026-08-15 | Northgate Medical Group | $332.00 | Approved |
| CLM-2026-011199 | 2026-01-31 | Summit Regional Medical Center | $915.00 | 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
No out-of-network benefit on this plan.