CLM-2026-016848
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-07-31 at independent laboratory (POS 81). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Katherine Carpenter
- Member ID
- UHC-20620-59
- Date of birth
- 1949-04-23
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-401206
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3317
- Coverage period
- 2021-09-01 to present
- Deductible
- $956.57 of $3,500.0027%
- Out-of-pocket maximum
- $462.96 of $10,500.004%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7837946178
- Network
- In network
- Rendering NPI
- 7837946178
- Location
- Miami, FL · TIN 25-9657303
- 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 | $81.00 | $50.22 | $50.22 | $0.00 | Paid |
| Totals | $81.00 | $50.22 | $50.22 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-167443
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006438 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-31: SELECT-EPO (EPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 7 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 Mesa Clinical Laboratories (7837946178). | |
| 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: Mesa Clinical Laboratories2026-07-31 18:04
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-08-07 05:25
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-167443.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011985 | 2026-03-26 | Canyon Medical Group | $356.00 | Needs review |
| CLM-2026-013648 | 2026-01-11 | Riverside Internal Medicine Associates | $256.00 | Denied |
| CLM-2026-013647 | 2026-01-11 | Riverside Internal Medicine Associates | $256.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.