CLM-2026-008018
Evergreen Reference Lab, Clinical Laboratory. Service 2026-01-03 at independent laboratory (POS 81). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Jonathan Ward
- Member ID
- UHC-26295-65
- Date of birth
- 2003-10-01
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-408606
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-6037
- Coverage period
- 2024-12-01 to present
- Deductible
- $2,529.66 of $3,500.0072%
- Out-of-pocket maximum
- $2,555.22 of $7,000.0037%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- 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 | 59 | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1 | $62.00 | $38.44 | — | — | Review |
| Totals | $99.00 | $61.38 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-513737
- 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-004947 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-03: NULL (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 13 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 | Pass | In-network provider Evergreen Reference Lab (6979403576). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Evergreen Reference Lab2026-01-03 17:20
Patient seen for urinary tract infection, site not specified. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-16 05:03
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-513737.pdf14 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.