CLM-2026-012870
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-05-08 at independent laboratory (POS 81). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Randy Soto
- Member ID
- UHC-23233-32
- Date of birth
- 1943-12-07
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-423628
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7919
- Coverage period
- 2022-04-01 to 2026-04-04
- Deductible
- $896.91 of $1,500.0060%
- Out-of-pocket maximum
- $2,174.66 of $4,500.0048%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | $68.00 | $30.60 | — | — | DeniedCO27 |
| Totals | $68.00 | $30.60 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-183130
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009048 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-08 is after coverage terminated on 2026-04-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Cornerstone Reference Lab2026-05-08 16:29
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-15 05:47
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-15 15:19
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 2026-05-08 is after coverage terminated on 2026-04-04. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021440 | 2026-03-16 | Mesa Clinical Laboratories | $86.00 | Approved |
| CLM-2026-006714 | 2026-03-10 | Desert Primary Care Associates | $233.00 | 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
Service after coverage termination.