CLM-2026-012453
Lakeside Reference Lab, Clinical Laboratory. Service 2026-03-20 at independent laboratory (POS 81). Received 2026-04-28.
Member
Resolved through the identity graph
- Member
- Benjamin Morgen
- Member ID
- UHC-99637-20
- Date of birth
- 1941-05-03
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-404721
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2025-01-01 to present
- Deductible
- $32.64 of $500.007%
- Out-of-pocket maximum
- $100.53 of $2,000.005%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7601465819
- Network
- In network
- Rendering NPI
- 7601465819
- Location
- Charlotte, NC · TIN 32-5251661
- 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 | — | 1 | 1 | $40.00 | $24.80 | — | — | Review |
| 2 | 87086 | Urine culture | 25 | 1 | 1 | $49.00 | $30.38 | — | — | Review |
| Totals | $89.00 | $55.18 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-974532
- 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-026783 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-03-20: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 39 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 Lakeside Reference Lab (7601465819). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Reference Lab2026-03-20 17:02
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-28 04:06
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-28 14:28
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011448 | 2026-03-22 | Meadow Bone and Joint Center | $1,618.00 | Approved |
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
Development letter outstanding.