CLM-2026-026391
Mesa Clinical Laboratories, Clinical Laboratory. Service 2025-12-16 at independent laboratory (POS 81). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Ralph Carpenter
- Member ID
- UHC-69808-22
- Date of birth
- 1967-06-11
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-408440
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7166
- Coverage period
- 2021-09-01 to present
- Deductible
- $414.92 of $2,500.0017%
- Out-of-pocket maximum
- $1,618.19 of $5,000.0032%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2023964945
- Network
- Out of network
- Rendering NPI
- 2023964945
- Location
- Atlanta, GA · TIN 12-9444799
- 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 | $70.00 | $31.50 | — | — | DeniedCO204 |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $50.00 | $22.50 | — | — | DeniedCO204 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1 | $73.00 | $32.85 | — | — | DeniedCO204 |
| 4 | 85025 | Complete blood count with differential | — | 1 | 1 | $51.00 | $22.95 | — | — | DeniedCO204 |
| Totals | $244.00 | $109.80 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-389034
- 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-004249 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-16: SELECT-EPO (EPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 29 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 | Fail | CO204 | Billing provider 2023964945 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Mesa Clinical Laboratories2025-12-16 16:56
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-14 03:31
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2023964945 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028469 | 2026-01-22 | Riverside Digestive Health Center | $5,122.00 | 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
No out-of-network benefit on this plan.