CLM-2026-025175
Mesa Reference Lab, Clinical Laboratory. Service 2025-10-20 at independent laboratory (POS 81). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Jonathan Vega
- Member ID
- UHC-70582-68
- Date of birth
- 1952-03-24
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420835
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5158
- Coverage period
- 2023-04-01 to present
- Deductible
- $739.22 of $1,500.0049%
- Out-of-pocket maximum
- $918.48 of $6,000.0015%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1578442364
- Network
- In network
- Rendering NPI
- 1578442364
- Location
- Scottsdale, AZ · TIN 27-6614149
- 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 | $67.00 | $41.54 | — | — | DeniedCO29 |
| Totals | $67.00 | $41.54 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-414760
- 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-008292 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-20: MEDICARE-ADV-A (MA), effective 2023-04-01. | |
| Timely filing | Fail | CO29 | Received 159 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Reference Lab (1578442364). | |
| 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 Reference Lab2025-10-20 12:25
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-28 01:56
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-28 16:26
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 12:44Timely filing: Received 159 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011312 | 2026-04-14 | Summit Diagnostic Imaging | $2,340.00 | Needs review |
| CLM-2026-013916 | 2026-02-12 | Summit Reference Lab | $51.00 | 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
Received after the timely-filing limit.