CLM-2026-020980
Desert Reference Lab, Clinical Laboratory. Service 2026-04-21 at independent laboratory (POS 81). Received 2026-05-10.
Member
Resolved through the identity graph
- Member
- Nicholas Carr
- Member ID
- UHC-93074-69
- Date of birth
- 1989-07-01
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-429261
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5960
- Coverage period
- 2024-03-01 to present
- Deductible
- $255.19 of $1,000.0026%
- Out-of-pocket maximum
- $741.40 of $2,000.0037%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5138952598
- Network
- Out of network
- Rendering NPI
- 5138952598
- Location
- Mesa, AZ · TIN 53-1049966
- Authorisation / referral
- none / REF880836
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 | $33.00 | $14.85 | — | — | DeniedCO204 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $51.00 | $22.95 | — | — | DeniedCO204 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $52.00 | $23.40 | — | — | DeniedCO204 |
| Totals | $136.00 | $61.20 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-131752
- 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-018998 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-21: NAVIGATE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 19 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 5138952598 is out of network and the HMO 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: Desert Reference Lab2026-04-21 18:15
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-10 00:20
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5138952598 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014586 | 2026-10-11 | Desert Medical Group | $787.00 | Approved |
| CLM-2026-004050 | 2026-05-12 | Mesa Diabetes Center | $150.00 | Approved |
| CLM-2026-012059 | 2026-02-03 | Sunrise Internal Medicine Associates | $571.00 | 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
No out-of-network benefit on this plan.