CLM-2026-024859
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-06-04 at independent laboratory (POS 81). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Gloria Richardson
- Member ID
- UHC-97404-89
- Date of birth
- 1981-06-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414420
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9519
- Coverage period
- 2024-05-01 to present
- Deductible
- $748.74 of $1,000.0075%
- Out-of-pocket maximum
- $573.68 of $2,000.0029%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 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 / REF427379
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 | 80061 | Lipid panel | — | 1 | 1 | $83.00 | $37.35 | — | — | DeniedCO204 |
| 2 | 85025 | Complete blood count with differential | 25 | 1 | 2 | $44.00 | $19.80 | — | — | DeniedCO204 |
| Totals | $127.00 | $57.15 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-266438
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004448 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-04: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 26 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 5966486339 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: Cornerstone Reference Lab2026-06-04 17:22
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-30 03:58
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-30 09:22
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 5966486339 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.