CLM-2026-016203
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-04-11 at independent laboratory (POS 81). Received 2026-09-01.
Member
Resolved through the identity graph
- Member
- Beverly Hughes
- Member ID
- UHC-84048-28
- Date of birth
- 1988-06-28
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-405735
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8923
- Coverage period
- 2022-06-01 to present
- Deductible
- $195.14 of $1,000.0020%
- Out-of-pocket maximum
- $639.04 of $2,000.0032%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7665709730
- Network
- In network
- Rendering NPI
- 7665709730
- Location
- Mesa, AZ · TIN 27-4199484
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $39.00 | $24.18 | — | — | DeniedCO29 |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $47.00 | $29.14 | — | — | DeniedCO29 |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO29 |
| Totals | $135.00 | $83.70 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-635501
- 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-039856 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-11: CHOICE-PLUS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Fail | CO29 | Received 143 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Clinical Laboratories (7665709730). | |
| 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: Summit Clinical Laboratories2026-04-11 09:24
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-09-01 02:15
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 143 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000493 | 2026-09-28 | Canyon Heart Institute | $1,601.00 | Approved |
| CLM-2026-003381 | 2026-08-02 | Canyon Medical Group | $302.00 | Approved |
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
Received after the timely-filing limit.