CLM-2026-023744
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-02-13 at independent laboratory (POS 81). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Joseph Howard
- Member ID
- UHC-87595-03
- Date of birth
- 1968-04-25
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-406612
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6236
- Coverage period
- 2023-02-01 to 2026-06-09
- Deductible
- $1,334.94 of $1,500.0089%
- Out-of-pocket maximum
- $1,797.55 of $4,500.0040%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $68.00 | $30.60 | — | — | DeniedCO18 |
| Totals | $68.00 | $30.60 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-665560
- 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 | Pass | Attached to MBR-018818 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-13: CHOICE-PLUS-PPO (PPO), effective 2023-02-01, terms 2026-06-09. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023743: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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: Cornerstone Reference Lab2026-02-13 16:05
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-13 06:20
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-023743: same member, date of service, procedures and billing provider. 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023743 | 2026-02-13 | Cornerstone Reference Lab | $68.00 | 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.