CLM-2026-009397
Evergreen Clinical Laboratories, Clinical Laboratory. Service 2026-01-07 at independent laboratory (POS 81). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Karen Padilla
- Member ID
- UHC-05442-22
- Date of birth
- 1998-05-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419519
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9339
- Coverage period
- 2022-09-01 to 2026-04-12
- Deductible
- $171.54 of $500.0034%
- Out-of-pocket maximum
- $950.97 of $2,000.0048%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5984537261
- Network
- In network
- Rendering NPI
- 5984537261
- Location
- Mesa, AZ · TIN 92-1302766
- Authorisation / referral
- none / REF303808
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 | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO18 |
| Totals | $49.00 | $30.38 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-472091
- 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-008173 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-07: NAVIGATE-HMO (HMO), effective 2022-09-01, terms 2026-04-12. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-009396: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Clinical Laboratories (5984537261). | |
| 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 Clinical Laboratories2026-01-07 17:31
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-03 04:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-03 14:52
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 13:43Duplicate check: Exact duplicate of CLM-2026-009396: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012968 | 2026-09-09 | Lakeside Orthopedic Specialists | $192.00 | Denied |
| CLM-2026-006579 | 2026-05-20 | Evergreen Primary Care Associates | $2,010.00 | Denied |
| CLM-2026-009396 | 2026-01-07 | Evergreen Clinical Laboratories | $49.00 | 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
Exact duplicate of an earlier submission.