CLM-2026-018956
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2025-07-23 at independent laboratory (POS 81). Received 2026-02-14.
Member
Resolved through the identity graph
- Member
- Evelyn Graham
- Member ID
- UHC-18366-77
- Date of birth
- 1968-03-17
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-422179
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5232
- Coverage period
- 2022-02-01 to present
- Deductible
- $218.43 of $500.0044%
- Out-of-pocket maximum
- $997.81 of $2,000.0050%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4658545775
- Network
- In network
- Rendering NPI
- 4658545775
- Location
- Nashville, TN · TIN 46-3944413
- 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 | $43.00 | $26.66 | — | — | DeniedCO29 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $74.00 | $45.88 | — | — | DeniedCO29 |
| Totals | $117.00 | $72.54 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-179681
- 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-005585 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-07-23: MEDICARE-ADV-B (MA), effective 2022-02-01. | |
| Timely filing | Fail | CO29 | Received 206 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Clinical Laboratories (4658545775). | |
| 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: Lakeside Clinical Laboratories2025-07-23 09:35
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-14 06:50
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 206 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031731 | 2026-01-05 | Riverside Primary Care Associates | $551.00 | 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
Received after the timely-filing limit.