CLM-2026-014869
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-07-01 at independent laboratory (POS 81). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Ralph Rodriguez
- Member ID
- none on golden record
- Date of birth
- 1991-08-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431979
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-3438
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,310.82 of $1,500.0087%
- Out-of-pocket maximum
- $564.31 of $3,000.0019%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3818568156
- Network
- In network
- Rendering NPI
- 3818568156
- Location
- Tempe, AZ · TIN 76-4810137
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $48.00 | $29.76 | — | — | PendedIDQ |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $55.00 | $34.10 | — | — | PendedIDQ |
| 3 | 87086 | Urine culture | 25 | 1 | 2 | $45.00 | $27.90 | — | — | PendedIDQ |
| Totals | $148.00 | $91.76 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-649441
- 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 | Fail | IDQ | Member record is in open steward case CASE-004151; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-01: CORE-HMO (HMO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 45 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 Mesa Clinical Laboratories (3818568156). | |
| 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 Laboratories2026-07-01 13:36
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-004151; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-01: CORE-HMO (HMO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014870 | 2026-07-01 | Valley Reference Lab | $148.00 | Pended |
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
Clean claim, priced at contract rate.