CLM-2026-014375
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-06-04 at independent laboratory (POS 81). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Luis Richards
- Member ID
- UHC-28814-43
- Date of birth
- 1969-08-21
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409421
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8626
- Coverage period
- 2022-04-01 to 2026-03-17
- Deductible
- $30.20 of $1,000.003%
- Out-of-pocket maximum
- $1,380.62 of $4,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5775545838
- Network
- In network
- Rendering NPI
- 5775545838
- Location
- Miami, FL · TIN 91-7135882
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $52.00 | $32.24 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $80.00 | $49.60 | — | — | DeniedCO27 |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $84.00 | $52.08 | — | — | DeniedCO27 |
| Totals | $216.00 | $133.92 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-648513
- 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-006113 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-04 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 (5775545838). | |
| 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 Clinical Laboratories2026-06-04 16:45
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-15 02:13
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 2026-06-04 is after coverage terminated on 2026-03-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018222 | 2026-07-28 | Meadow GI Associates | $301.00 | Denied |
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.