CLM-2026-011576
Mesa Reference Lab, Clinical Laboratory. Service 2025-12-04 at independent laboratory (POS 81). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Raymond Walsh
- Member ID
- UHC-09175-90
- Date of birth
- 1951-11-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400012
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7045
- Coverage period
- 2025-09-01 to present
- Deductible
- $981.92 of $1,500.0065%
- Out-of-pocket maximum
- $1,105.40 of $4,500.0025%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 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 | 85025 | Complete blood count with differential | 59 | 1 | 1 | $46.00 | $28.52 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1 | $90.00 | $55.80 | — | — | Review |
| Totals | $136.00 | $84.32 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-928944
- 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-000241 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-04: N/A (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 28 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) | 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Reference Lab2025-12-04 13:59
Established patient presents with essential (primary) hypertension; 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 system2026-01-01 02:51
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-928944.pdf7 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 engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:05The claim uses modifier 59 on a code pair that is normally bundled (85025 and 80053). The clinical note [N1] and the medical record [A1] both indicate that the procedures were performed at the same site during the same session, which contradicts the use of modifier 59. According to the NCCI edit [R-ncci], this is not a distinct procedural service, so the claim is denied with reason code CO97.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 3adc457a
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026673 | 2026-07-23 | Pinecrest Cardiovascular Associates | $283.00 | Approved |
| CLM-2026-022863 | 2026-06-21 | Northgate Clinical Laboratories | $135.00 | Approved |
| CLM-2026-029724 | 2025-12-29 | Canyon Internal Medicine Associates | $2,372.00 | Needs review |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim uses modifier 59 on a code pair that is normally bundled (85025 and 80053). The clinical note [N1] and the medical record [A1] both indicate that the procedures were performed at the same site during the same session, which contradicts the use of modifier 59. According to the NCCI edit [R-ncci], this is not a distinct procedural service, so the claim is denied with reason code CO97.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.