CLM-2026-006903
Summit Reference Lab, Clinical Laboratory. Service 2026-05-22 at independent laboratory (POS 81). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Wayne Howard
- Member ID
- UHC-15907-37
- Date of birth
- 1957-01-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431389
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7107
- Coverage period
- 2024-12-01 to 2026-04-02
- Deductible
- $208.83 of $2,500.008%
- Out-of-pocket maximum
- $1,480.36 of $7,500.0020%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7256801888
- Network
- Out of network
- Rendering NPI
- 7256801888
- Location
- Scottsdale, AZ · TIN 41-8218808
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $44.00 | $19.80 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $76.00 | $34.20 | — | — | DeniedCO27 |
| Totals | $120.00 | $54.00 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-939954
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018406 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-22 is after coverage terminated on 2026-04-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Summit Reference Lab2026-05-22 16:08
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-17 02:33
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-22 is after coverage terminated on 2026-04-02. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030145 | 2026-05-07 | Mesa Orthopedic Specialists | $1,659.00 | Denied |
| CLM-2026-014137 | 2026-03-06 | Summit Clinical Laboratories | $2,217.00 | Needs review |
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
Service after coverage termination.