CLM-2026-010334
Pinecrest Reference Lab, Clinical Laboratory. Service 2026-03-19 at independent laboratory (POS 81). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Jerry Pierce
- Member ID
- none on golden record
- Date of birth
- 2004-02-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401470
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-3862
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,157.98 of $2,500.0046%
- Out-of-pocket maximum
- $3,234.05 of $7,500.0043%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4399070182
- Network
- In network
- Rendering NPI
- 4399070182
- Location
- Houston, TX · TIN 93-0870375
- 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 | 87086 | Urine culture | — | 1 | 1 | $30.00 | $18.60 | — | — | PendedIDQ |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $44.00 | $27.28 | — | — | PendedIDQ |
| 3 | 80061 | Lipid panel | — | 1 | 1,2 | $36.00 | $22.32 | — | — | PendedIDQ |
| Totals | $110.00 | $68.20 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-238381
- 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 | Fail | IDQ | Member record is in open steward case CASE-000055; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-19: MEDICARE-ADV-B (MA), effective 2021-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 24 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 Pinecrest Reference Lab (4399070182). | |
| 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: Pinecrest Reference Lab2026-03-19 18:16
Established patient presents with urinary tract infection, site not specified; 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 13:43Member identity: Member record is in open steward case CASE-000055; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-19: MEDICARE-ADV-B (MA), effective 2021-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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.