CLM-2026-008995
Summit Reference Lab, Clinical Laboratory. Service 2026-02-01 at independent laboratory (POS 81). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Ashley Edwards
- Member ID
- none on golden record
- Date of birth
- 1970-10-22
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429958
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Eligibility
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 | 87086 | Urine culture | — | 1 | 1 | $32.00 | $14.40 | — | — | PendedN30 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $60.00 | $27.00 | — | — | PendedN30 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $61.00 | $27.45 | — | — | PendedN30 |
| Totals | $153.00 | $68.85 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-526645
- 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-020182 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 44 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 Lab2026-02-01 18:52
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. 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-2026-006437 | 2026-02-15 | Pinecrest Physical Therapy | $253.00 | Pended |
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.