CLM-2026-026257
Pinecrest Clinical Laboratories, Clinical Laboratory. Service 2026-06-05 at independent laboratory (POS 81). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Loi Carter
- Member ID
- UHC-77348-46
- Date of birth
- 1978-12-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-413908
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4603
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,261.94 of $3,500.0036%
- Out-of-pocket maximum
- $3,606.91 of $10,500.0034%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6068288409
- Network
- In network
- Rendering NPI
- 6068288409
- Location
- San Diego, CA · TIN 41-0079440
- 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 | 87086 | Urine culture | — | 1 | 1 | $54.00 | $33.48 | — | — | PendedIDQ |
| Totals | $54.00 | $33.48 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-183387
- 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 | Fail | IDQ | Member record is in open steward case CASE-003774; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-05: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 39 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 | Pass | In-network provider Pinecrest Clinical Laboratories (6068288409). | |
| 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: Pinecrest Clinical Laboratories2026-06-05 10:51
Patient seen for urinary tract infection, site not specified.
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-003774; payment withheld until the identity is confirmed.
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.