Claims workbench/CLM-2026-012204
Professional claim · CMS-1500 · EDI 837P

CLM-2026-012204

Evergreen Reference Lab, Clinical Laboratory. Service 2026-01-21 at independent laboratory (POS 81). Received 2026-08-25.

Denied
Billed
$61.00
1 line
Allowed
$37.82
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Santiago Romero
Member ID
UHC-67527-13
Date of birth
1978-11-20
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-417457
Relationship
Self, Houston, TX

Coverage and accumulators

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-3967
Coverage period
2021-12-01 to present
Deductible
$304.89 of $1,500.0020%
Out-of-pocket maximum
$354.03 of $6,000.006%
Copays
office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits
19 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI
6979403576
Network
In network
Rendering NPI
6979403576
Location
Miami, FL · TIN 38-5459375
Authorisation / referral
none / REF928194

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
183036Hemoglobin A1c—11$61.00$37.82——DeniedCO29
Totals$61.00$37.82——
Diagnoses (ICD-10-CM)
  • 1. N39.0 Urinary tract infection, site not specifiedprincipal
  • 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
Patient account
PA-951920
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

CheckResultCodeDetail
Member identityPassAttached to MBR-042454 (verified, link confidence 1.00).
EligibilityPassActive on 2026-01-21: NAVIGATE-HMO (HMO), effective 2021-12-01.
Timely filingFailCO29Received 216 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Reference Lab (6979403576).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Evergreen Reference Lab2026-01-21 12:11

    Patient seen for urinary tract infection, site not specified.

  • SystemSystem: Claims system2026-08-25 05:31

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Timely filing: Received 216 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity