CLM-2026-020045
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-05-09 at independent laboratory (POS 81). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Cheryl Armstrong
- Member ID
- UHC-23457-56
- Date of birth
- 1967-04-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-428432
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5859
- Coverage period
- 2024-04-01 to present
- Deductible
- $569.91 of $3,500.0016%
- Out-of-pocket maximum
- $2,811.06 of $14,000.0020%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7665709730
- Network
- In network
- Rendering NPI
- 7665709730
- Location
- Mesa, AZ · TIN 27-4199484
- Authorisation / referral
- none / REF741796
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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $70.00 | $43.40 | — | — | DeniedCO18 |
| 2 | 85025 | Complete blood count with differential | 25 | 1 | 2 | $47.00 | $29.14 | — | — | DeniedCO18 |
| Totals | $117.00 | $72.54 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-650322
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015934 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-09: NAVIGATE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 54 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-020044: 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 Summit Clinical Laboratories (7665709730). | |
| 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: Summit Clinical Laboratories2026-05-09 10:36
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-07-02 03:04
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-020044: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029165 | 2026-06-25 | Harbor Primary Care Associates | $434.00 | Approved |
| CLM-2026-020044 | 2026-05-09 | Summit Clinical Laboratories | $117.00 | Approved |
| CLM-2026-017475 | 2026-01-21 | Summit Reference Lab | $166.00 | 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.