CLM-2026-023429
Desert Clinical Laboratories, Clinical Laboratory. Service 2025-12-07 at independent laboratory (POS 81). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Gregory Pierce
- Member ID
- UHC-34020-29
- Date of birth
- 1951-01-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419025
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7818
- Coverage period
- 2021-02-01 to present
- Deductible
- $262.75 of $3,500.008%
- Out-of-pocket maximum
- $1,944.35 of $10,500.0019%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9068366761
- Network
- In network
- Rendering NPI
- 9068366761
- Location
- Houston, TX · TIN 28-8573609
- 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 | 87086 | Urine culture | — | 1 | 1 | $43.00 | $26.66 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $43.00 | $26.66 | — | — | Review |
| Totals | $86.00 | $53.32 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-175983
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001259 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-07: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-023428; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Clinical Laboratories (9068366761). | |
| 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: Desert Clinical Laboratories2025-12-07 17:33
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-08 04:23
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-023428.pdf1 page
Provider cover letter requesting replacement of CLM-2026-023428.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-023428; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-21 14:15The claim is a replacement for an earlier claim with an error in the units billed for one of the services. The provider has submitted a corrected claim with the correct units. The member is eligible, the provider is in-network, and the services are medically necessary and not bundled. The claim is within the auto-adjudication ceiling and all required documentation is present. The original claim must be voided when this replacement claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 1b1cc12d
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034322 | 2026-05-20 | Unity Family Practice | $453.00 | Needs review |
| CLM-2026-023428 | 2025-12-07 | Desert Clinical Laboratories | $86.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is a replacement for an earlier claim with an error in the units billed for one of the services. The provider has submitted a corrected claim with the correct units. The member is eligible, the provider is in-network, and the services are medically necessary and not bundled. The claim is within the auto-adjudication ceiling and all required documentation is present. The original claim must be voided when this replacement claim is approved.
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
Replacement claim supersedes the original.