CLM-2026-024874
Heritage Clinical Laboratories, Clinical Laboratory. Service 2025-12-13 at independent laboratory (POS 81). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Angela Reid
- Member ID
- none on golden record
- Date of birth
- 1943-08-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401778
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Heritage Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6061087964
- Network
- In network
- Rendering NPI
- 6061087964
- Location
- Scottsdale, AZ · TIN 58-0891898
- 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 | $64.00 | $39.68 | — | — | PendedN30 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $56.00 | $34.72 | — | — | PendedN30 |
| 3 | 87086 | Urine culture | 25 | 1 | 1,2 | $46.00 | $28.52 | — | — | PendedN30 |
| 4 | 85025 | Complete blood count with differential | — | 1 | 2 | $64.00 | $39.68 | — | — | PendedN30 |
| Totals | $230.00 | $142.60 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-242311
- 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-000435 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 20 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 | Pass | In-network provider Heritage Clinical Laboratories (6061087964). | |
| 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: Heritage Clinical Laboratories2025-12-13 18:04
Patient seen for urinary tract infection, site not specified.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.