CLM-2026-013715
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-04-09 at independent laboratory (POS 81). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Robetr Ruiz
- Member ID
- UHC-81591-66
- Date of birth
- 1994-03-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422622
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- - PPO group -
- Coverage period
- 2021-02-01 to present
- Deductible
- $886.64 of $2,500.0035%
- Out-of-pocket maximum
- $1,524.37 of $10,000.0015%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2382593988
- Network
- In network
- Rendering NPI
- 2382593988
- Location
- Atlanta, GA · TIN 17-8035936
- 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 | 87086 | Urine culture | — | 1 | 1 | $70.00 | $43.40 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $68.00 | $42.16 | — | — | DeniedCO29 |
| 3 | 80061 | Lipid panel | 25 | 1 | 1 | $50.00 | $31.00 | — | — | DeniedCO29 |
| Totals | $188.00 | $116.56 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-570665
- 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-038237 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-09: - (PPO), effective 2021-02-01. | |
| Timely filing | Fail | CO29 | Received 95 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Clinical Laboratories (2382593988). | |
| 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: Mesa Clinical Laboratories2026-04-09 16:03
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-13 03:59
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 95 days after the last date of service (limit 90).
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
Received after the timely-filing limit.