CLM-2026-017439
Desert Reference Lab, Clinical Laboratory. Service 2025-12-30 at independent laboratory (POS 81). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Keith Diaz
- Member ID
- UHC-14729-92
- Date of birth
- 1996-11-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-420503
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4082
- Coverage period
- 2023-03-01 to present
- Deductible
- $209.26 of $1,000.0021%
- Out-of-pocket maximum
- $166.33 of $3,000.006%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8770600343
- Network
- In network
- Rendering NPI
- 8770600343
- Location
- Charlotte, NC · TIN 95-8427409
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $69.00 | $42.78 | — | — | DeniedCO18 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $43.00 | $26.66 | — | — | DeniedCO18 |
| Totals | $112.00 | $69.44 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-654841
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006571 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-30: SELECT-EPO (EPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-017438: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Reference Lab (8770600343). | |
| 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: Desert Reference Lab2025-12-30 11:00
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-02-08 06:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-08 09:04
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-017438: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017438 | 2025-12-30 | Desert Reference Lab | $112.00 | 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
Exact duplicate of an earlier submission.