CLM-2026-009210
Summit Reference Lab, Clinical Laboratory. Service 2025-12-27 at independent laboratory (POS 81). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Jerry Hoffman
- Member ID
- UHC-04371-18
- Date of birth
- 1942-07-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423223
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4387
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,971.89 of $3,500.0056%
- Out-of-pocket maximum
- $1,339.14 of $14,000.0010%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
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 / REF756457
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 | $41.00 | $18.45 | — | — | DeniedCO204 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $34.00 | $15.30 | — | — | DeniedCO204 |
| Totals | $75.00 | $33.75 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-152649
- 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-011790 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-27: CORE-HMO (HMO), effective 2024-09-01. | |
| 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 | Fail | CO204 | Billing provider 7256801888 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Lab2025-12-27 09:19
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-09 02:31
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-09 11:55
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7256801888 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.