Professional claim · CMS-1500 · EDI 837P
CLM-2026-021845
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-03-22 at independent laboratory (POS 81). Received 2026-05-02.
Denied
Billed
$142.00
3 lines
Allowed
$88.04
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Judith Jacobs
- Member ID
- UHC-48697-92
- Date of birth
- 1941-10-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406307
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5550
- Coverage period
- 2023-04-01 to 2026-02-03
- Deductible
- $14.16 of $1,000.001%
- Out-of-pocket maximum
- $810.38 of $3,000.0027%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 8920689386
- Network
- In network
- Rendering NPI
- 8920689386
- Location
- Mesa, AZ · TIN 50-3391688
- Authorisation / referral
- none / REF724449
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 | $40.00 | $24.80 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $50.00 | $31.00 | — | — | DeniedCO27 |
| 3 | 80061 | Lipid panel | 25 | 1 | 1 | $52.00 | $32.24 | — | — | DeniedCO27 |
| Totals | $142.00 | $88.04 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-523375
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006479 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-22 is after coverage terminated on 2026-02-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 Clinical Laboratories (8920689386). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Clinical Laboratories2026-03-22 18:14
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-05-02 06:30
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-22 is after coverage terminated on 2026-02-03.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033711 | 2025-12-18 | Summit Counseling Center | $253.00 | Approved |
| CLM-2026-018217 | 2026-01-15 | Pinecrest GI Associates | $1,434.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.