CLM-2026-015367
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-08-23 at independent laboratory (POS 81). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Logan Bell
- Member ID
- UHC-88125-05
- Date of birth
- 1970-08-22
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-404462
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3352
- Coverage period
- 2023-10-01 to 2026-06-06
- Deductible
- $2,098.46 of $2,500.0084%
- Out-of-pocket maximum
- $768.16 of $7,500.0010%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2217213752
- Network
- In network
- Rendering NPI
- 2217213752
- Location
- San Diego, CA · TIN 57-4449871
- Authorisation / referral
- none / REF192074
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 | 83036 | Hemoglobin A1c | 59 | 1 | 1 | $51.00 | $31.62 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1 | $71.00 | $44.02 | — | — | DeniedCO27 |
| Totals | $122.00 | $75.64 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-677550
- 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-027917 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-23 is after coverage terminated on 2026-06-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 Harbor Clinical Laboratories (2217213752). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Harbor Clinical Laboratories2026-08-23 16:54
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-05 03:29
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-05 15:19
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-08-23 is after coverage terminated on 2026-06-06. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029909 | 2026-09-11 | Valley Reference Lab | $3,426.00 | 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.