CLM-2026-021130
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-08-15 at independent laboratory (POS 81). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Timothy Yang
- Member ID
- UHC-70570-53
- Date of birth
- 1954-04-02
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-408608
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1011
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,092.71 of $1,500.0073%
- Out-of-pocket maximum
- $1,822.22 of $4,500.0040%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3818568156
- Network
- In network
- Rendering NPI
- 3818568156
- Location
- Tempe, AZ · TIN 76-4810137
- 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 | $50.00 | $31.00 | $31.00 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $56.00 | $34.72 | $34.72 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $52.00 | $32.24 | $32.24 | $0.00 | Paid |
| Totals | $158.00 | $97.96 | $97.96 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-651942
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002156 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-15: NAVIGATE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 37 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 Mesa Clinical Laboratories (3818568156). | |
| 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: Mesa Clinical Laboratories2026-08-15 18:27
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-21 05:15
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-21 14:10
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-651942.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.