CLM-2026-014174
Meadow Reference Lab, Clinical Laboratory. Service 2026-02-24 at independent laboratory (POS 81). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Jonathan Kennedy
- Member ID
- UHC-96291-49
- Date of birth
- 1961-12-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428302
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8224
- Coverage period
- 2025-10-01 to present
- Deductible
- $327.39 of $500.0065%
- Out-of-pocket maximum
- $746.12 of $2,000.0037%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 3840164321
- Network
- Out of network
- Rendering NPI
- 3840164321
- Location
- Los Angeles, CA · TIN 14-8564922
- Authorisation / referral
- none / REF659515
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 | $88.00 | $39.60 | — | — | DeniedCO204 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $45.00 | $20.25 | — | — | DeniedCO204 |
| Totals | $133.00 | $59.85 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-741943
- 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-017459 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-24: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 8 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 | Fail | CO204 | Billing provider 3840164321 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Meadow Reference Lab2026-02-24 15:00
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-03-04 03:52
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3840164321 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.