CLM-2026-016525
Lakeside Reference Lab, Clinical Laboratory. Service 2026-07-10 at independent laboratory (POS 81). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Jacqueline Padilla
- Member ID
- UHC-58059-62
- Date of birth
- 1984-07-25
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-413583
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7679
- Coverage period
- 2022-11-01 to present
- Deductible
- $855.54 of $1,500.0057%
- Out-of-pocket maximum
- $43.70 of $3,000.001%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5657642919
- Network
- In network
- Rendering NPI
- 5657642919
- Location
- Charlotte, NC · TIN 76-9243358
- 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 | $47.00 | $29.14 | — | — | Review |
| Totals | $47.00 | $29.14 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-414788
- 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-001889 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-10: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 21 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 Lakeside Reference Lab (5657642919). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with urinary tract infection, site not specified; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Reference Lab2026-07-10 17:26
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-31 05:50
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-31 15:20
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with urinary tract infection, site not specified; symptoms re”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023652 | 2026-05-31 | Harbor Diabetes Center | $481.00 | Needs review |
| CLM-2026-023651 | 2026-05-31 | Harbor Diabetes Center | $481.00 | Approved |
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
Development letter outstanding.