CLM-2026-022537
Mesa Reference Lab, Clinical Laboratory. Service 2026-08-22 at independent laboratory (POS 81). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Katherine Dean
- Member ID
- UHC-59897-08
- Date of birth
- 1958-12-09
- Identity
- Verified4 records, confidence 0.87
- Claim record
- CLMCLM-404025
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3945
- Coverage period
- 2025-05-01 to 2026-08-28
- Deductible
- $287.34 of $500.0057%
- Out-of-pocket maximum
- $416.81 of $1,500.0028%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1578442364
- Network
- In network
- Rendering NPI
- 1578442364
- Location
- Scottsdale, AZ · TIN 27-6614149
- 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 | 80061 | Lipid panel | — | 1 | 1 | $51.00 | $31.62 | — | — | DeniedCO18 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO18 |
| 3 | 83036 | Hemoglobin A1c | 25 | 1 | 1 | $56.00 | $34.72 | — | — | DeniedCO18 |
| Totals | $156.00 | $96.72 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-468554
- 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-035595 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-08-22: MEDICARE-ADV-B (MA), effective 2025-05-01, terms 2026-08-28. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-022536: 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 Mesa Reference Lab (1578442364). | |
| 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 Reference Lab2026-08-22 15:42
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-31 02:31
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-31 13:50
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 12:44Duplicate check: Exact duplicate of CLM-2026-022536: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024070 | 2026-08-26 | Sunrise Clinical Laboratories | $185.00 | Approved |
| CLM-2026-022536 | 2026-08-22 | Mesa Reference Lab | $156.00 | 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.