CLM-2026-022571
Meadow Reference Lab, Clinical Laboratory. Service 2026-01-20 at independent laboratory (POS 81). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Margaret Patel
- Member ID
- none on golden record
- Date of birth
- 1991-06-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-432821
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-2105
- Coverage period
- 2023-02-01 to 2026-03-13
- Deductible
- $442.99 of $500.0089%
- Out-of-pocket maximum
- $501.45 of $2,000.0025%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 3840164321
- Network
- Out of network
- Rendering NPI
- 3840164321
- Location
- Los Angeles, CA · TIN 14-8564922
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $74.00 | $33.30 | — | — | PendedIDQ |
| Totals | $74.00 | $33.30 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-689126
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000685; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-01-20: OPTIONS-PPO (PPO), effective 2023-02-01, terms 2026-03-13. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 36 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: Meadow Reference Lab2026-01-20 13:49
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-02-25 06:56
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-25 08:57
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-689126.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000685; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-20: OPTIONS-PPO (PPO), effective 2023-02-01, terms 2026-03-13. Coverage found by name and date of birth because the claim carried no usable member ID. 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
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.