CLM-2026-021885
Heritage Clinical Laboratories, Clinical Laboratory. Service 2026-02-08 at independent laboratory (POS 81). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Gerald Anderson
- Member ID
- UHC-60914-75
- Date of birth
- 1999-08-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-430441
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3457
- Coverage period
- 2024-07-01 to present
- Deductible
- $478.56 of $1,000.0048%
- Out-of-pocket maximum
- $1,698.52 of $4,000.0042%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1717512853
- Network
- In network
- Rendering NPI
- 1717512853
- Location
- Atlanta, GA · TIN 95-9962981
- 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 | $68.00 | $42.16 | — | — | DeniedCO18 |
| Totals | $68.00 | $42.16 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-115663
- 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-004914 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-08: SELECT-EPO (EPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021884: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Clinical Laboratories (1717512853). | |
| 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: Heritage Clinical Laboratories2026-02-08 12:44
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-27 04:18
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-27 11:40
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-021884: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007426 | 2026-06-24 | Desert Internal Medicine Associates | $2,835.00 | Needs review |
| CLM-2026-021884 | 2026-02-08 | Heritage Clinical Laboratories | $68.00 | Approved |
| CLM-2026-024167 | 2026-02-09 | Canyon Medical Group | $390.00 | Approved |
| CLM-2026-002381 | 2025-12-24 | Meadow Primary Care Associates | $221.00 | 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
Exact duplicate of an earlier submission.