CLM-2026-026375
Summit Clinical Laboratories, Clinical Laboratory. Service 2025-10-10 at independent laboratory (POS 81). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- Ryan Hill
- Member ID
- UHC-29944-94
- Date of birth
- 1961-04-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413092
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1486
- Coverage period
- 2023-03-01 to present
- Deductible
- $567.07 of $1,500.0038%
- Out-of-pocket maximum
- $861.56 of $3,000.0029%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7688028761
- Network
- In network
- Rendering NPI
- 7688028761
- Location
- Los Angeles, CA · TIN 67-3598965
- 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 | 80061 | Lipid panel | — | 1 | 1 | $57.00 | $35.34 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | — | 1 | 2 | $43.00 | $26.66 | — | — | DeniedCO29 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1 | $68.00 | $42.16 | — | — | DeniedCO29 |
| Totals | $168.00 | $104.16 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-552083
- 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-024807 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-10: SELECT-EPO (EPO), effective 2023-03-01. | |
| 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 Summit Clinical Laboratories (7688028761). | |
| 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: Summit Clinical Laboratories2025-10-10 15:38
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-04-09 04:56
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-09 16:41
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 181 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.