CLM-2026-007191
Mesa Reference Lab, Clinical Laboratory. Service 2026-08-31 at independent laboratory (POS 81). Received 2026-10-22.
Member
Resolved through the identity graph
- Member
- Ahmed Vega
- Member ID
- UHC-03347-26
- Date of birth
- 1953-09-25
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-426948
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8683
- Coverage period
- 2023-05-01 to present
- Deductible
- $158.70 of $1,500.0011%
- Out-of-pocket maximum
- $374.72 of $4,500.008%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1578442364
- Network
- In network
- Rendering NPI
- 1578442364
- Location
- Scottsdale, AZ · TIN 27-6614149
- 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 | $33.00 | $20.46 | — | — | DeniedCO18 |
| 2 | 80061 | Lipid panel | 25 | 1 | 2 | $56.00 | $34.72 | — | — | DeniedCO18 |
| Totals | $89.00 | $55.18 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-820548
- 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-026655 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-31: OPTIONS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 52 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-007190: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Reference Lab (1578442364). | |
| 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: Mesa Reference Lab2026-08-31 16:03
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-10-22 05:00
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-007190: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007190 | 2026-08-31 | Mesa Reference Lab | $89.00 | Approved |
| CLM-2026-012049 | 2026-05-08 | Meadow Physical Therapy | $354.00 | Approved |
| CLM-2026-011933 | 2026-05-19 | Harbor Medical Group | $216.00 | 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
Exact duplicate of an earlier submission.