CLM-2026-019202
Harbor Clinical Laboratories, Clinical Laboratory. Service 2025-07-19 at independent laboratory (POS 81). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Carolyn Price
- Member ID
- UHC-44884-39
- Date of birth
- 1983-07-27
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-424782
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6852
- Coverage period
- 2023-09-01 to present
- Deductible
- $390.10 of $500.0078%
- Out-of-pocket maximum
- $272.69 of $1,500.0018%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2217213752
- Network
- In network
- Rendering NPI
- 2217213752
- Location
- San Diego, CA · TIN 57-4449871
- 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 | 87086 | Urine culture | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1,2 | $89.00 | $55.18 | — | — | DeniedCO29 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $61.00 | $37.82 | — | — | DeniedCO29 |
| Totals | $199.00 | $123.38 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-715916
- 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-010829 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-07-19: MEDICARE-ADV-A (MA), effective 2023-09-01. | |
| Timely filing | Fail | CO29 | Received 202 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 Harbor Clinical Laboratories (2217213752). | |
| 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 Clinical Laboratories2025-07-19 14:05
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-06 00:01
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-06 11:08
Member services inquiry logged on this claim; member asked about the status of payment.
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 202 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030836 | 2026-05-06 | Lakeside Reference Lab | $70.00 | 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.