CLM-2026-016485
Summit Reference Lab, Clinical Laboratory. Service 2025-12-22 at independent laboratory (POS 81). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Ralph Grreen
- Member ID
- UHC-95379-38
- Date of birth
- 1994-02-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425296
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3926
- Coverage period
- 2025-03-01 to present
- Deductible
- $110.37 of $1,000.0011%
- Out-of-pocket maximum
- $1,595.51 of $4,000.0040%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7256801888
- Network
- Out of network
- Rendering NPI
- 7256801888
- Location
- Scottsdale, AZ · TIN 41-8218808
- 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 | $53.00 | $23.85 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $64.00 | $28.80 | — | — | DeniedCO29 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1 | $69.00 | $31.05 | — | — | DeniedCO29 |
| Totals | $186.00 | $83.70 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-690829
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031573 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: - (PPO), effective 2025-03-01. | |
| Timely filing | Fail | CO29 | Received 149 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Reference Lab2025-12-22 16:37
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-05-20 01:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-20 13:26
Called the provider office; awaiting documentation.
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 149 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Received after the timely-filing limit.