CLM-2026-022368
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-03-23 at independent laboratory (POS 81). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Catherine Robinson
- Member ID
- UHC-29027-31
- Date of birth
- 1945-09-28
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-401983
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group NULL
- Coverage period
- 2023-11-01 to 2026-01-12
- Deductible
- $2,081.50 of $2,500.0083%
- Out-of-pocket maximum
- $2,578.11 of $10,000.0026%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2023964945
- Network
- Out of network
- Rendering NPI
- 2023964945
- Location
- Atlanta, GA · TIN 12-9444799
- 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 | $66.00 | $29.70 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | — | 1 | 2 | $60.00 | $27.00 | — | — | DeniedCO27 |
| Totals | $126.00 | $56.70 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-856337
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024049 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-23 is after coverage terminated on 2026-01-12. 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Laboratories2026-03-23 11:37
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-05 03:38
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-05 11:13
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-23 is after coverage terminated on 2026-01-12. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.