CLM-2026-012471
Heritage Clinical Laboratories, Clinical Laboratory. Service 2026-06-11 at independent laboratory (POS 81). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Kathryn Thompson
- Member ID
- UHC-66658-75
- Date of birth
- 1988-02-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-426850
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1748
- Coverage period
- 2022-01-01 to 2026-02-21
- Deductible
- $846.18 of $3,500.0024%
- Out-of-pocket maximum
- $406.72 of $7,000.006%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6061087964
- Network
- In network
- Rendering NPI
- 6061087964
- Location
- Scottsdale, AZ · TIN 58-0891898
- 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 | — | 1 | 1 | $53.00 | $32.86 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $69.00 | $42.78 | — | — | DeniedCO27 |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $44.00 | $27.28 | — | — | DeniedCO27 |
| Totals | $166.00 | $102.92 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-230873
- 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-011910 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-02-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 Heritage Clinical Laboratories (6061087964). | |
| 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: Heritage Clinical Laboratories2026-06-11 17:47
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-26 04:19
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-26 11:14
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-11 is after coverage terminated on 2026-02-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027847 | 2026-07-30 | Lakeside Endocrine Associates | $377.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.