CLM-2026-025441
Valley Clinical Laboratories, Clinical Laboratory. Service 2026-05-14 at independent laboratory (POS 81). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Bryan Henderson
- Member ID
- none on golden record
- Date of birth
- 1964-03-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404959
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-6156
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,066.37 of $3,500.0030%
- Out-of-pocket maximum
- $1,918.25 of $10,500.0018%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5408693625
- Network
- Out of network
- Rendering NPI
- 5408693625
- Location
- Tampa, FL · TIN 43-5217451
- 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 | $33.00 | $14.85 | — | — | PendedIDQ |
| 2 | 87086 | Urine culture | — | 1 | 1 | $34.00 | $15.30 | — | — | PendedIDQ |
| Totals | $67.00 | $30.15 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-404578
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002894; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-14: OPTIONS-PPO (PPO), effective 2021-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 3 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Clinical Laboratories2026-05-14 09:20
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002894; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-14: OPTIONS-PPO (PPO), effective 2021-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.