CLM-2026-017312
Summit Reference Lab, Clinical Laboratory. Service 2026-03-07 at independent laboratory (POS 81). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Willie Chavez
- Member ID
- UHC-34974-99
- Date of birth
- 2007-02-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-427351
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0541
- Coverage period
- 2025-11-01 to present
- Deductible
- $143.07 of $1,000.0014%
- Out-of-pocket maximum
- $951.18 of $3,000.0032%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 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 / REF762109
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 | $51.00 | $22.95 | — | — | DeniedCO204 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $73.00 | $32.85 | — | — | DeniedCO204 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 2 | $70.00 | $31.50 | — | — | DeniedCO204 |
| Totals | $194.00 | $87.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-732642
- 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-027005 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-07: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 45 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 | Fail | CO204 | Billing provider 7256801888 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Lab2026-03-07 15:45
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-04-21 03:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-21 08:40
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7256801888 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023852 | 2026-07-05 | Mesa Diabetes Center | $216.00 | Approved |
| CLM-2026-000817 | 2026-01-23 | Northgate Heart Institute | $1,341.00 | Denied |
| CLM-2026-005417 | 2026-05-01 | Pinecrest Medical Group | $154.00 | Approved |
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
No out-of-network benefit on this plan.