CLM-2026-016777
Evergreen Clinical Laboratories, Clinical Laboratory. Service 2026-09-22 at independent laboratory (POS 81). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Jesse Hughes
- Member ID
- UHC-62926-91
- Date of birth
- 1956-06-22
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-405440
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3970
- Coverage period
- 2021-03-01 to 2026-01-22
- Deductible
- $72.68 of $500.0015%
- Out-of-pocket maximum
- $610.62 of $2,000.0031%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5984537261
- Network
- In network
- Rendering NPI
- 5984537261
- Location
- Mesa, AZ · TIN 92-1302766
- 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 | $80.00 | $49.60 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | 25 | 1 | 1 | $47.00 | $29.14 | — | — | DeniedCO27 |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $34.00 | $21.08 | — | — | DeniedCO27 |
| Totals | $161.00 | $99.82 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-159056
- 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-004505 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-22 is after coverage terminated on 2026-01-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 17 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 Evergreen Clinical Laboratories (5984537261). | |
| 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: Evergreen Clinical Laboratories2026-09-22 13:22
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-10-09 04:13
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 2026-09-22 is after coverage terminated on 2026-01-22.
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
Service after coverage termination.