CLM-2026-015618
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-05-26 at independent laboratory (POS 81). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- William Dean
- Member ID
- UHC-57472-02
- Date of birth
- 1981-02-05
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400129
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2294
- Coverage period
- 2021-04-01 to 2026-01-19
- Deductible
- $193.21 of $500.0039%
- Out-of-pocket maximum
- $175.87 of $1,500.0012%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2122435433
- Network
- Out of network
- Rendering NPI
- 2122435433
- Location
- Los Angeles, CA · TIN 12-4722693
- 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 | 87086 | Urine culture | — | 1 | 1 | $70.00 | $31.50 | — | — | DeniedCO27 |
| Totals | $70.00 | $31.50 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-107562
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004221 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-26 is after coverage terminated on 2026-01-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 2122435433 is out of network and the EPO 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: Harbor Clinical Laboratories2026-05-26 11:31
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-30 04:55
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-30 09:05
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-26 is after coverage terminated on 2026-01-19. Provider network: Billing provider 2122435433 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004274 | 2026-08-19 | Unity Cardiovascular Associates | $649.00 | 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.