CLM-2026-015757
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-08-05 at independent laboratory (POS 81). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Ommar Schmidt
- Member ID
- UHC-75827-81
- Date of birth
- 1974-03-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404795
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8919
- Coverage period
- 2021-06-01 to 2026-04-08
- Deductible
- $1,707.51 of $2,500.0068%
- Out-of-pocket maximum
- $3,934.52 of $10,000.0039%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 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 / 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 | $59.00 | $36.58 | — | — | DeniedCO27 |
| Totals | $59.00 | $36.58 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-465383
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038048 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-05 is after coverage terminated on 2026-04-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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) | 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 Laboratories2026-08-05 12:08
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-24 00:45
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-24 09:57
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-05 is after coverage terminated on 2026-04-08.
Other claims for this member
Same resolved identity
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.