CLM-2026-026813
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-06-16 at independent laboratory (POS 81). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- David Yang
- Member ID
- UHC-06564-81
- Date of birth
- 2008-01-27
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-410216
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0989
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,427.49 of $2,500.0057%
- Out-of-pocket maximum
- $1,628.31 of $5,000.0033%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4740334576
- Network
- In network
- Rendering NPI
- 4740334576
- Location
- Mesa, AZ · TIN 57-0560500
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $40.00 | $24.80 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $51.00 | $31.62 | — | — | Review |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $49.00 | $30.38 | — | — | Review |
| Totals | $140.00 | $86.80 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-991737
- 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-018330 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-16: MEDICARE-ADV-B (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 11 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 Cornerstone Reference Lab (4740334576). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with urinary tract infection, site not specified; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Reference Lab2026-06-16 15:45
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-27 00:34
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-27 09:58
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with urinary tract infection, site not specified; symptoms re”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033591 | 2026-09-08 | Valley Reference Lab | $40.00 | Approved |
| CLM-2026-002008 | 2026-06-20 | Evergreen Primary Care Associates | $310.00 | Approved |
| CLM-2026-034032 | 2026-02-21 | Mesa Medical Group | $583.00 | Approved |
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
Development letter outstanding.