CLM-2026-010199
Valley Clinical Laboratories, Clinical Laboratory. Service 2026-09-23 at independent laboratory (POS 81). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Melissa Hudson
- Member ID
- UHC-49229-90
- Date of birth
- 2007-09-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431907
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7518
- Coverage period
- 2021-10-01 to 2026-05-16
- Deductible
- $1,064.63 of $2,500.0043%
- Out-of-pocket maximum
- $1,729.12 of $5,000.0035%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5408693625
- Network
- Out of network
- Rendering NPI
- 5408693625
- Location
- Tampa, FL · TIN 43-5217451
- Authorisation / referral
- none / REF972771
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 | $64.00 | $28.80 | — | — | DeniedCO27 |
| Totals | $64.00 | $28.80 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-165199
- 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 | Pass | Attached to MBR-015560 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-23 is after coverage terminated on 2026-05-16. Expenses incurred after coverage terminated |
| 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 | Fail | CO204 | Billing provider 5408693625 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: Valley Clinical Laboratories2026-09-23 14:23
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-12 04:12
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-12 14:53
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-23 is after coverage terminated on 2026-05-16. Provider network: Billing provider 5408693625 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002182 | 2026-02-16 | Sunrise Physical Therapy | $183.00 | 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
Service after coverage termination.