CLM-2026-012474
Harbor Reference Lab, Clinical Laboratory. Service 2026-06-09 at independent laboratory (POS 81). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Kevin Mitchell
- Member ID
- UHC-59458-43
- Date of birth
- 1962-07-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432004
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6567
- Coverage period
- 2023-03-01 to 2026-02-06
- Deductible
- $243.80 of $500.0049%
- Out-of-pocket maximum
- $459.19 of $2,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4121885428
- Network
- In network
- Rendering NPI
- 4121885428
- Location
- Tempe, AZ · TIN 21-1131562
- 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 | 80061 | Lipid panel | — | 1 | 1 | $35.00 | $21.70 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $40.00 | $24.80 | — | — | DeniedCO27 |
| Totals | $75.00 | $46.50 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-953896
- 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-013362 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-09 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 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 Harbor Reference Lab (4121885428). | |
| 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: Harbor Reference Lab2026-06-09 15:33
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-15 00:24
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-15 09:00
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-09 is after coverage terminated on 2026-02-06.
Other claims for this member
Same resolved identity
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.