CLM-2026-008260
Evergreen Reference Lab, Clinical Laboratory. Service 2026-07-29 at independent laboratory (POS 81). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Bobby Ferguson
- Member ID
- none on golden record
- Date of birth
- 1975-12-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426726
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4205
- Coverage period
- 2024-02-01 to present
- Deductible
- $167.43 of $500.0033%
- Out-of-pocket maximum
- $411.75 of $1,000.0041%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $70.00 | $43.40 | — | — | PendedIDQ |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $74.00 | $45.88 | — | — | PendedIDQ |
| 3 | 80061 | Lipid panel | 25 | 1 | 1 | $52.00 | $32.24 | — | — | PendedIDQ |
| Totals | $196.00 | $121.52 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-942644
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003052; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-29: CHOICE-PLUS-PPO (PPO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 19 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) | 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: Evergreen Reference Lab2026-07-29 17:48
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003052; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-29: CHOICE-PLUS-PPO (PPO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.