CLM-2026-016834
Evergreen Reference Lab, Clinical Laboratory. Service 2026-08-11 at independent laboratory (POS 81). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Teresa Fisher
- Member ID
- UHC-20504-81
- Date of birth
- 1959-04-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425717
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1960
- Coverage period
- 2023-02-01 to present
- Deductible
- $1,282.05 of $1,500.0085%
- Out-of-pocket maximum
- $1,309.14 of $4,500.0029%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- 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 | 80061 | Lipid panel | — | 1 | 1 | $55.00 | $34.10 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $72.00 | $44.64 | — | — | Review |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $86.00 | $53.32 | — | — | Review |
| 4 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $31.00 | $19.22 | — | — | Review |
| Totals | $244.00 | $151.28 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-257112
- 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-009576 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-11: CHOICE-PLUS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 27 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 Reference Lab (6979403576). | |
| 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: “Follow-up for urinary tract infection, site not specified. Plan discussed, medications rec”. 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: Evergreen Reference Lab2026-08-11 12:56
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-07 06:53
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-07 09:11
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: “Follow-up for urinary tract infection, site not specified. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009196 | 2026-08-20 | Cornerstone Reference Lab | $132.00 | Approved |
| CLM-2026-013543 | 2026-07-24 | Northgate Internal Medicine Associates | $242.00 | Approved |
| CLM-2026-032274 | 2026-05-26 | Harbor Reference Lab | $98.00 | Approved |
| CLM-2026-006904 | 2025-12-18 | Meadow GI Associates | $2,897.00 | 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
Development letter outstanding.