CLM-2026-023993
Desert Reference Lab, Clinical Laboratory. Service 2026-09-01 at independent laboratory (POS 81). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Jose Owens
- Member ID
- UHC-07892-04
- Date of birth
- 1962-08-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-407866
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4038
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,207.36 of $2,500.0048%
- Out-of-pocket maximum
- $672.94 of $7,500.009%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5138952598
- Network
- Out of network
- Rendering NPI
- 5138952598
- Location
- Mesa, AZ · TIN 53-1049966
- Authorisation / referral
- none / REF636345
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 | 85025 | Complete blood count with differential | — | 1 | 1 | $48.00 | $21.60 | — | — | DeniedCO204 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $30.00 | $13.50 | — | — | DeniedCO204 |
| Totals | $78.00 | $35.10 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-840535
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004123 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-01: CORE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 32 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 | Fail | CO204 | Billing provider 5138952598 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Reference Lab2026-09-01 16:53
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-10-03 01:05
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5138952598 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.