Claims workbench/CLM-2026-011575

Professional claim · CMS-1500 · EDI 837P

CLM-2026-011575

Desert Reference Lab, Clinical Laboratory. Service 2026-01-27 at independent laboratory (POS 81). Received 2026-02-05.

Needs reviewOut of network

Billed

$150.00

3 lines

Allowed

$67.50

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Donald Simpson
Member ID: UHC-22050-94
Date of birth: 1976-07-23
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-432468
Relationship: Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-8249
Coverage period: 2022-12-01 to present
Deductible: $2,967.31 of $3,500.0085%
Out-of-pocket maximum: $2,511.83 of $7,000.0036%
Copays: office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Desert Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI: 5138952598
Network: Out of network
Rendering NPI: 5138952598
Location: Mesa, AZ · TIN 53-1049966
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	59	1	1	$41.00	$18.45	—	—	Review
2	85025	Complete blood count with differential	59	1	2	$35.00	$15.75	—	—	Review
3	83036	Hemoglobin A1c	—	1	2	$74.00	$33.30	—	—	Review
Totals						$150.00	$67.50	—	—

Diagnoses (ICD-10-CM)

1. N39.0 Urinary tract infection, site not specifiedprincipal

Claim header

Patient account: PA-679136
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-008385 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-27: MEDICARE-ADV-A (MA), effective 2022-12-01.
Timely filing	Pass		Received 9 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Desert Reference Lab2026-01-27 12:58
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-02-05 03:14
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-05 15:27
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Medical recordrecords_PA-679136.pdf18 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-026319	2026-08-27	Evergreen Family Practice	$17.00	Approved
CLM-2026-005715	2025-12-26	Desert Primary Care Associates	$226.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity