CLM-2026-015237
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-06-29 at independent laboratory (POS 81). Received 2026-07-11.
Member
Resolved through the identity graph
- Member
- Bradley Bryant
- Member ID
- UHC-99924-03
- Date of birth
- 1990-12-16
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-422950
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2578
- Coverage period
- 2024-02-01 to 2026-03-21
- Deductible
- $309.49 of $500.0062%
- Out-of-pocket maximum
- $615.57 of $1,500.0041%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | $55.00 | $24.75 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $58.00 | $26.10 | — | — | DeniedCO27 |
| 3 | 80061 | Lipid panel | — | 1 | 1,2 | $63.00 | $28.35 | — | — | DeniedCO27 |
| Totals | $176.00 | $79.20 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-473920
- 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 | Pass | Attached to MBR-000275 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-29 is after coverage terminated on 2026-03-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Cornerstone Reference Lab2026-06-29 14:38
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-11 03:43
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-11 09:55
Escalated to nurse reviewer for clinical opinion.
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 2026-06-29 is after coverage terminated on 2026-03-21. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009458 | 2026-07-22 | Meadow Heart Institute | $8,372.00 | 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.