CLM-2026-012688
Heritage Clinical Laboratories, Clinical Laboratory. Service 2026-02-11 at independent laboratory (POS 81). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Patricia Ray
- Member ID
- UHC-60766-67
- Date of birth
- 1993-04-14
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-403036
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5467
- Coverage period
- 2024-05-01 to present
- Deductible
- $379.16 of $2,500.0015%
- Out-of-pocket maximum
- $2,063.56 of $7,500.0028%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 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 | $52.00 | $32.24 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $52.00 | $32.24 | — | — | DeniedCO18 |
| Totals | $104.00 | $64.48 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-818566
- 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-019456 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-11: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 52 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012687: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Laboratories2026-02-11 14:11
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-04 02:32
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-04 11:52
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-012687: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012687 | 2026-02-11 | Heritage Clinical Laboratories | $104.00 | Approved |
| CLM-2026-016360 | 2026-01-27 | Lakeside Bone and Joint Center | $205.00 | Approved |
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
Exact duplicate of an earlier submission.