Professional claim · CMS-1500 · EDI 837P
CLM-2026-026680
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-03-31 at independent laboratory (POS 81). Received 2026-04-21.
Denied
Billed
$57.00
1 line
Allowed
$35.34
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ahmed Wells
- Member ID
- UHC-76495-59
- Date of birth
- 1988-02-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410759
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1906
- Coverage period
- 2024-01-01 to 2026-02-11
- Deductible
- $320.91 of $500.0064%
- Out-of-pocket maximum
- $176.71 of $1,000.0018%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6855554898
- Network
- In network
- Rendering NPI
- 6855554898
- Location
- Scottsdale, AZ · TIN 20-9059141
- Authorisation / referral
- none / REF466465
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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $57.00 | $35.34 | — | — | DeniedCO27 |
| Totals | $57.00 | $35.34 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-425631
- 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-016834 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-31 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Meadow Clinical Laboratories (6855554898). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Clinical Laboratories2026-03-31 17:24
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-04-21 02:20
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-31 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006795 | 2026-03-03 | Northgate Internal Medicine Associates | $367.00 | Denied |
| CLM-2026-031707 | 2026-02-25 | Pinecrest Primary Care Associates | $31.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.