CLM-2026-010024
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-05-22 at independent laboratory (POS 81). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Joe Richards
- Member ID
- none on golden record
- Date of birth
- 1945-09-03
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-412894
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3912329836
- Network
- In network
- Rendering NPI
- 3912329836
- Location
- Nashville, TN · TIN 38-7470413
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $63.00 | $39.06 | — | — | PendedN30 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $86.00 | $53.32 | — | — | PendedN30 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $59.00 | $36.58 | — | — | PendedN30 |
| 4 | 87086 | Urine culture | — | 1 | 1,2 | $49.00 | $30.38 | — | — | PendedN30 |
| Totals | $257.00 | $159.34 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-133519
- 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-032204 (verified, link confidence 0.93). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 3 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 Summit Clinical Laboratories (3912329836). | |
| 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 Clinical Laboratories2026-05-22 18:44
Established patient presents with hyperlipidemia, unspecified; 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 enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031957 | 2026-05-19 | Heritage Internal Medicine Associates | $3,181.00 | 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.