CLM-2026-024049
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-09-02 at independent laboratory (POS 81). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Larry Chapman
- Member ID
- UHC-59123-12
- Date of birth
- 1972-12-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400181
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0775
- Coverage period
- 2022-10-01 to present
- Deductible
- $180.60 of $1,500.0012%
- Out-of-pocket maximum
- $1,398.00 of $3,000.0047%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5775545838
- Network
- In network
- Rendering NPI
- 5775545838
- Location
- Miami, FL · TIN 91-7135882
- Authorisation / referral
- none / REF837836
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 | $54.00 | $33.48 | — | — | DeniedCO18 |
| Totals | $54.00 | $33.48 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-340788
- 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-026601 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-02: NAVIGATE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024048: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Clinical Laboratories (5775545838). | |
| 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 Clinical Laboratories2026-09-02 18:17
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-09-22 06:21
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-22 09:16
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-024048: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024048 | 2026-09-02 | Meadow Clinical Laboratories | $54.00 | Approved |
| CLM-2026-013979 | 2026-05-03 | Lakeside Internal Medicine Associates | $560.00 | 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.