Professional claim · CMS-1500 · EDI 837P
CLM-2026-017372
Lakeside Reference Lab, Clinical Laboratory. Service 2026-04-09 at independent laboratory (POS 81). Received 2026-05-14.
Denied
Billed
$68.00
1 line
Allowed
$42.16
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Abigail Hicks
- Member ID
- UHC-46842-79
- Date of birth
- 2001-04-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407485
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2410
- Coverage period
- 2023-02-01 to 2026-02-04
- Deductible
- $2,839.23 of $3,500.0081%
- Out-of-pocket maximum
- $464.32 of $7,000.007%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 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 / REF553948
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $68.00 | $42.16 | — | — | DeniedCO27 |
| Totals | $68.00 | $42.16 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-575547
- 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-011217 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-09 is after coverage terminated on 2026-02-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Reference Lab2026-04-09 16:22
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-05-14 01:29
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-09 is after coverage terminated on 2026-02-04.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004741 | 2026-08-13 | Northgate Reference Lab | $143.00 | Denied |
| CLM-2026-000352 | 2026-07-04 | Meadow Family Practice | $33.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.