CLM-2026-025719
Valley Reference Lab, Clinical Laboratory. Service 2026-07-17 at independent laboratory (POS 81). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Kelly Lucas
- Member ID
- UHC-15635-05
- Date of birth
- 1947-12-15
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-423178
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0972
- Coverage period
- 2023-02-01 to present
- Deductible
- $1,025.55 of $2,500.0041%
- Out-of-pocket maximum
- $4,629.53 of $10,000.0046%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8777376848
- Network
- In network
- Rendering NPI
- 8777376848
- Location
- Minneapolis, MN · TIN 45-5717570
- Authorisation / referral
- none / REF294593
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 | 80061 | Lipid panel | — | 1 | 1 | $40.00 | $24.80 | — | — | DeniedCO18 |
| Totals | $40.00 | $24.80 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-755146
- 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-005452 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-17: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-025718: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Reference Lab (8777376848). | |
| 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 Reference Lab2026-07-17 12:28
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-18 06:05
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-18 12:53
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-025718: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025718 | 2026-07-17 | Valley Reference Lab | $40.00 | Approved |
| CLM-2026-010329 | 2026-02-27 | Evergreen Family Practice | $582.00 | Approved |
| CLM-2026-032615 | 2026-01-01 | Canyon Reference Lab | $147.00 | Denied |
| CLM-2026-032614 | 2026-01-01 | Evergreen Clinical Laboratories | $147.00 | 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
Exact duplicate of an earlier submission.