CLM-2026-016207
Cornerstone Clinical Laboratories, Clinical Laboratory. Service 2026-04-19 at independent laboratory (POS 81). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Yuki Bryant
- Member ID
- UHC-69518-70
- Date of birth
- 1999-06-25
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416351
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group N/A
- Coverage period
- 2022-08-01 to 2026-06-10
- Deductible
- $19.91 of $500.004%
- Out-of-pocket maximum
- $470.00 of $2,000.0024%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5304802437
- Network
- In network
- Rendering NPI
- 5304802437
- Location
- Atlanta, GA · TIN 72-2370295
- 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 | $58.00 | $35.96 | — | — | PendedIDQ |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $75.00 | $46.50 | — | — | PendedIDQ |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $30.00 | $18.60 | — | — | PendedIDQ |
| Totals | $163.00 | $101.06 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-529785
- 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 | Fail | IDQ | Member record is in open steward case CASE-002635; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-19: N/A (PPO), effective 2022-08-01, terms 2026-06-10. | |
| 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 Cornerstone Clinical Laboratories (5304802437). | |
| 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: Cornerstone Clinical Laboratories2026-04-19 12:00
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002635; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016208 | 2026-04-19 | Cornerstone Clinical Laboratories | $163.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.