CLM-2026-020159
Lakeside Reference Lab, Clinical Laboratory. Service 2026-03-05 at independent laboratory (POS 81). Received 2026-03-29.
Member
Resolved through the identity graph
- Member
- Tyler Vargas
- Member ID
- none on golden record
- Date of birth
- 1980-01-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418766
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-2525
- Coverage period
- 2025-04-01 to 2026-01-20
- Deductible
- $820.51 of $1,000.0082%
- Out-of-pocket maximum
- $1,793.58 of $4,000.0045%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8593662793
- Network
- In network
- Rendering NPI
- 8593662793
- Location
- Austin, TX · TIN 19-8347023
- 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 | $46.00 | $28.52 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $68.00 | $42.16 | — | — | DeniedCO27 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $31.00 | $19.22 | — | — | DeniedCO27 |
| Totals | $145.00 | $89.90 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-259054
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000684; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-03-05 is after coverage terminated on 2026-01-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| 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 Reference Lab (8593662793). | |
| 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 Reference Lab2026-03-05 10:25
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-03-29 04:56
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-29 11:31
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 engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000684; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-03-05 is after coverage terminated on 2026-01-20.
Other claims for this member
Same resolved identity
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
Service after coverage termination.