CLM-2026-010206
Mesa Reference Lab, Clinical Laboratory. Service 2026-08-05 at independent laboratory (POS 81). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Joseph Carroll
- Member ID
- UHC-92686-44
- Date of birth
- 1970-10-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419981
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3465
- Coverage period
- 2025-09-01 to 2026-03-27
- Deductible
- $1,987.39 of $2,500.0079%
- Out-of-pocket maximum
- $996.40 of $5,000.0020%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1578442364
- Network
- In network
- Rendering NPI
- 1578442364
- Location
- Scottsdale, AZ · TIN 27-6614149
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | — | 1 | 2 | $46.00 | $28.52 | — | — | DeniedCO27 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $64.00 | $39.68 | — | — | DeniedCO27 |
| Totals | $159.00 | $98.58 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-106650
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011577 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-05 is after coverage terminated on 2026-03-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 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 Mesa Reference Lab (1578442364). | |
| 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: Mesa Reference Lab2026-08-05 12:59
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-12 01:39
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-12 12:22
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-05 is after coverage terminated on 2026-03-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031510 | 2026-03-18 | Northgate Reference Lab | $170.00 | Needs review |
| CLM-2026-031509 | 2026-03-18 | Northgate Reference Lab | $170.00 | Approved |
| CLM-2026-028558 | 2026-02-05 | Lakeside Bone and Joint Center | $43,800.00 | Needs review |
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.