CLM-2026-025434
Harbor Reference Lab, Clinical Laboratory. Service 2025-08-27 at independent laboratory (POS 81). Received 2026-02-24.
Member
Resolved through the identity graph
- Member
- Dylan Martin
- Member ID
- UHC-41516-35
- Date of birth
- 1946-03-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-423138
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1571
- Coverage period
- 2024-08-01 to present
- Deductible
- $289.57 of $2,500.0012%
- Out-of-pocket maximum
- $1,014.11 of $5,000.0020%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4121885428
- Network
- In network
- Rendering NPI
- 4121885428
- Location
- Tempe, AZ · TIN 21-1131562
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO29 |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $46.00 | $28.52 | — | — | DeniedCO29 |
| 3 | 87086 | Urine culture | — | 1 | 1,2 | $57.00 | $35.34 | — | — | DeniedCO29 |
| Totals | $166.00 | $102.92 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-278444
- 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-015641 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-08-27: NULL (PPO), effective 2024-08-01. | |
| Timely filing | Fail | CO29 | Received 181 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 Harbor Reference Lab (4121885428). | |
| 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: Harbor Reference Lab2025-08-27 15:57
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-02-24 06:48
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 181 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031380 | 2026-09-01 | Summit Diagnostic Imaging | $890.00 | Approved |
| CLM-2026-031320 | 2026-05-27 | Summit Counseling Center | $462.00 | 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.