CLM-2026-019025
Evergreen Reference Lab, Clinical Laboratory. Service 2026-01-27 at independent laboratory (POS 81). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Brandon Graham
- Member ID
- UHC-81812-78
- Date of birth
- 1998-03-03
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-418370
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0555
- Coverage period
- 2022-12-01 to present
- Deductible
- $320.58 of $500.0064%
- Out-of-pocket maximum
- $599.91 of $1,500.0040%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $87.00 | $53.94 | — | — | DeniedCO29 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1 | $47.00 | $29.14 | — | — | DeniedCO29 |
| Totals | $134.00 | $83.08 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-598785
- 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-008948 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-27: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Fail | CO29 | Received 141 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 Evergreen Reference Lab (6979403576). | |
| 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: Evergreen Reference Lab2026-01-27 10:37
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-17 01:07
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-17 10:48
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 engineDenied2026-10-22 12:44Timely filing: Received 141 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022577 | 2026-03-01 | Desert Diagnostic Imaging | $3,536.00 | Denied |
| CLM-2026-022576 | 2026-03-01 | Desert Diagnostic Imaging | $3,536.00 | Approved |
| CLM-2026-000025 | 2026-01-18 | Pinecrest Medical Group | $490.00 | 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.