CLM-2026-020365
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-08-27 at independent laboratory (POS 81). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Ana Banks
- Member ID
- UHC-34703-52
- Date of birth
- 1968-01-12
- Identity
- Verified6 records, confidence 0.90
- Claim record
- CLMCLM-404327
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8002
- Coverage period
- 2023-04-01 to 2026-03-10
- Deductible
- $325.98 of $1,500.0022%
- Out-of-pocket maximum
- $652.66 of $3,000.0022%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $48.00 | $21.60 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $41.00 | $18.45 | — | — | DeniedCO27 |
| Totals | $89.00 | $40.05 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-137859
- 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 | Pass | Attached to MBR-011694 (verified, link confidence 0.90). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-27 is after coverage terminated on 2026-03-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 13 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 | Fail | CO204 | Billing provider 5966486339 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Cornerstone Reference Lab2026-08-27 18:38
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-09-09 00:02
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-09 08:14
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-27 is after coverage terminated on 2026-03-10. Provider network: Billing provider 5966486339 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008318 | 2026-07-18 | Riverside Community Hospital | $2,732.00 | Denied |
| CLM-2026-015021 | 2026-04-26 | Pinecrest Heart Institute | $1,353.00 | Denied |
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.