CLM-2026-022553
Lakeside Reference Lab, Clinical Laboratory. Service 2026-06-06 at independent laboratory (POS 81). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Karen Bishop
- Member ID
- none on golden record
- Date of birth
- 1939-10-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417814
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-6079
- Coverage period
- 2021-04-01 to present
- Deductible
- $350.90 of $1,000.0035%
- Out-of-pocket maximum
- $839.85 of $2,000.0042%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8593662793
- Network
- In network
- Rendering NPI
- 8593662793
- Location
- Austin, TX · TIN 19-8347023
- Authorisation / referral
- none / REF834325
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 | $79.00 | $48.98 | — | — | PendedIDQ |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $58.00 | $35.96 | — | — | PendedIDQ |
| 3 | 80061 | Lipid panel | — | 1 | 2 | $49.00 | $30.38 | — | — | PendedIDQ |
| Totals | $186.00 | $115.32 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-863880
- 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 | Fail | IDQ | Member record is in open steward case CASE-001044; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-06: NAVIGATE-HMO (HMO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 4 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 Reference Lab (8593662793). | |
| 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: Lakeside Reference Lab2026-06-06 17:35
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001044; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-06: NAVIGATE-HMO (HMO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.