CLM-2026-026540
Summit Reference Lab, Clinical Laboratory. Service 2026-08-18 at independent laboratory (POS 81). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Samuel Obrien
- Member ID
- UHC-78534-34
- Date of birth
- 2000-10-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-413398
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1802
- Coverage period
- 2021-03-01 to present
- Deductible
- $748.82 of $1,000.0075%
- Out-of-pocket maximum
- $1,109.27 of $4,000.0028%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2797853506
- Network
- In network
- Rendering NPI
- 2797853506
- Location
- Nashville, TN · TIN 64-6425854
- 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 | $49.00 | $30.38 | — | — | DeniedCO18 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $65.00 | $40.30 | — | — | DeniedCO18 |
| Totals | $114.00 | $70.68 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-549233
- 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-010329 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-18: UNKNOWN (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 57 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026539: 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 Summit Reference Lab (2797853506). | |
| 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 Reference Lab2026-08-18 18:19
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-10-14 06:56
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-14 14:50
Called the provider office; awaiting documentation.
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-2026-026539: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026539 | 2026-08-18 | Summit Reference Lab | $114.00 | 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.