CLM-2026-018548
Harbor Reference Lab, Clinical Laboratory. Service 2026-04-23 at independent laboratory (POS 81). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Frank Salazar
- Member ID
- UHC-98170-43
- Date of birth
- 1988-09-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-413190
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5393
- Coverage period
- 2024-04-01 to present
- Deductible
- $2,207.58 of $2,500.0088%
- Out-of-pocket maximum
- $3,065.67 of $10,000.0031%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4121885428
- Network
- In network
- Rendering NPI
- 7837946178 (Mesa Clinical Laboratories)
- Location
- Tempe, AZ · TIN 21-1131562
- Authorisation / referral
- none / REF467687
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 | 87086 | Urine culture | — | 1 | 1 | $59.00 | $36.58 | — | — | Review |
| Totals | $59.00 | $36.58 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-553796
- 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-029708 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-23: NAVIGATE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-018547, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Reference Lab (4121885428). | |
| 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: Harbor Reference Lab2026-04-23 16:46
Patient seen for hyperlipidemia, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-02 01:00
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-02 15:53
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 engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-018547, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002283 | 2026-07-03 | Riverside Primary Care Associates | $540.00 | Approved |
| CLM-2026-029567 | 2026-04-15 | Desert Regional Medical Center | $2,510.00 | Approved |
| CLM-2026-018547 | 2026-04-23 | Mesa Clinical Laboratories | $59.00 | Approved |
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
Different billing provider; separately payable.