CLM-2026-013595
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-01-13 at independent laboratory (POS 81). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Fatima Butler
- Member ID
- UHC-49073-83
- Date of birth
- 1972-06-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416017
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4640
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,157.04 of $2,500.0046%
- Out-of-pocket maximum
- $1,066.91 of $5,000.0021%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6855554898
- Network
- In network
- Rendering NPI
- 6855554898
- Location
- Scottsdale, AZ · TIN 20-9059141
- 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 | 59 | 1 | 1 | $76.00 | $47.12 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | 59 | 1 | 1 | $31.00 | $19.22 | — | — | Review |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $78.00 | $48.36 | — | — | Review |
| Totals | $185.00 | $114.70 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-947353
- 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-014985 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-13: - (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 40 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 Meadow Clinical Laboratories (6855554898). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Meadow Clinical Laboratories2026-01-13 11:29
Patient seen for essential (primary) hypertension. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-02-22 03:51
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-22 17:03
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-947353.pdf14 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029052 | 2026-07-22 | Riverside Primary Care Associates | $313.00 | Approved |
| CLM-2026-017302 | 2026-07-08 | Valley Clinical Laboratories | $97.00 | Denied |
| CLM-2026-022488 | 2026-06-21 | Summit Clinical Laboratories | $65.00 | Approved |
| CLM-2026-017301 | 2026-07-08 | Valley Clinical Laboratories | $97.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.