CLM-2026-015921
Pinecrest Reference Lab, Clinical Laboratory. Service 2026-06-10 at independent laboratory (POS 81). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Camila Phillips
- Member ID
- UHC-26863-57
- Date of birth
- 1977-11-17
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427331
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8555
- Coverage period
- 2022-11-01 to 2026-03-11
- Deductible
- $1,418.50 of $2,500.0057%
- Out-of-pocket maximum
- $2,128.05 of $7,500.0028%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4399070182
- Network
- In network
- Rendering NPI
- 4399070182
- Location
- Houston, TX · TIN 93-0870375
- 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 | $52.00 | $32.24 | — | — | DeniedCO27 |
| Totals | $52.00 | $32.24 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-922259
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001942 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-10 is after coverage terminated on 2026-03-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 Pinecrest Reference Lab (4399070182). | |
| 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: Pinecrest Reference Lab2026-06-10 13:22
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-12 06:40
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-12 08:54
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 2026-06-10 is after coverage terminated on 2026-03-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023922 | 2026-06-05 | Lakeside Medical Group | $25.00 | Denied |
| CLM-2026-017069 | 2026-04-08 | Pinecrest Reference Lab | $128.00 | 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.