Claims workbench/CLM-2026-024903

Professional claim · CMS-1500 · EDI 837P

CLM-2026-024903

Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-07-01 at independent laboratory (POS 81). Received 2026-07-20.

Needs reviewOut of network

Billed

$133.00

2 lines

Allowed

$59.85

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Bradley Jones
Member ID: UHC-59050-84
Date of birth: 1962-03-17
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-431203
Relationship: Self, Houston, TX

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-4108
Coverage period: 2023-08-01 to present
Deductible: $192.49 of $500.0038%
Out-of-pocket maximum: $204.00 of $1,000.0020%
Copays: office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits: 8 of 20 used

Provider

Billing and rendering

Billing provider: Harbor Clinical Laboratories
Clinical Laboratory · taxonomy 291U00000X
NPI: 2122435433
Network: Out of network
Rendering NPI: 2122435433
Location: Los Angeles, CA · TIN 12-4722693
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	$76.00	$34.20	—	—	Review
2	80053	Comprehensive metabolic panel	—	1	2	$57.00	$25.65	—	—	Review
Totals						$133.00	$59.85	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
2. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-595710
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-015973 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-01: OPTIONS-PPO (PPO), effective 2023-08-01.
Timely filing	Pass		Received 19 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Harbor Clinical Laboratories2026-07-01 10:21
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
SystemSystem: Claims system2026-07-20 06:06
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-20 17:15
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-020641	2026-06-27	Unity Family Practice	$159.00	Approved
CLM-2026-023160	2026-06-19	Valley Primary Care Associates	$13.00	Approved
CLM-2026-004901	2026-03-31	Sunrise Digestive Health Center	$248.00	Approved
CLM-2026-009956	2026-01-29	Pinecrest Internal Medicine Associates	$380.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity