CLM-2026-008183
Pinecrest Clinical Laboratories, Clinical Laboratory. Service 2025-11-27 at independent laboratory (POS 81). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Arthur Turner
- Member ID
- UHC-79544-73
- Date of birth
- 1996-10-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432259
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5727
- Coverage period
- 2025-06-01 to present
- Deductible
- $117.61 of $1,500.008%
- Out-of-pocket maximum
- $2,537.33 of $6,000.0042%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6068288409
- Network
- In network
- Rendering NPI
- 6068288409
- Location
- San Diego, CA · TIN 41-0079440
- 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 | 87086 | Urine culture | — | 1 | 1 | $46.00 | $28.52 | — | — | DeniedCO29 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $67.00 | $41.54 | — | — | DeniedCO29 |
| Totals | $113.00 | $70.06 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-623386
- 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-000642 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-27: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 171 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 Pinecrest Clinical Laboratories (6068288409). | |
| 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: Pinecrest Clinical Laboratories2025-11-27 13:38
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-05-17 06:04
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 171 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014608 | 2025-12-22 | Lakeside Clinical Laboratories | $138.00 | Approved |
| CLM-2026-016461 | 2025-12-25 | Lakeside Internal Medicine Associates | $380.00 | 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
Received after the timely-filing limit.