CLM-2026-024830
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-03-04 at independent laboratory (POS 81). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Lori Cruz
- Member ID
- UHC-87156-17
- Date of birth
- 1990-04-25
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-416815
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3498
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,309.40 of $1,500.0087%
- Out-of-pocket maximum
- $596.72 of $6,000.0010%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2382593988
- Network
- In network
- Rendering NPI
- 2382593988
- Location
- Atlanta, GA · TIN 17-8035936
- 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 | $60.00 | $37.20 | — | — | DeniedCO18 |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $73.00 | $45.26 | — | — | DeniedCO18 |
| Totals | $133.00 | $82.46 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-926316
- 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-026448 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-04: CHOICE-PLUS-PPO (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 63 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024829: 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 Mesa Clinical Laboratories (2382593988). | |
| 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: Mesa Clinical Laboratories2026-03-04 10:28
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-06 04:23
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-024829: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015961 | 2026-05-27 | Valley Imaging Center | $2,378.00 | Approved |
| CLM-2026-024829 | 2026-03-04 | Mesa Clinical Laboratories | $133.00 | 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.