CLM-2026-022534
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-04-16 at independent laboratory (POS 81). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Sara Burke
- Member ID
- UHC-67629-21
- Date of birth
- 1969-04-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-424425
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1927
- Coverage period
- 2024-02-01 to present
- Deductible
- $958.70 of $3,500.0027%
- Out-of-pocket maximum
- $2,445.39 of $10,500.0023%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 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 / REF932717
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 | 80061 | Lipid panel | — | 1 | 1 | $50.00 | $22.50 | — | — | DeniedCO204 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $51.00 | $22.95 | — | — | DeniedCO204 |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $45.00 | $20.25 | — | — | DeniedCO204 |
| Totals | $146.00 | $65.70 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-883703
- 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-031576 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-16: CORE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 34 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 2023964945 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: Mesa Clinical Laboratories2026-04-16 09:50
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-20 04:28
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-20 10:22
Called the provider office; awaiting documentation.
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 2023964945 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.