CLM-2026-027075
Heritage Clinical Laboratories, Clinical Laboratory. Service 2025-12-30 at independent laboratory (POS 81). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Roy Alexander
- Member ID
- UHC-29043-03
- Date of birth
- 1975-11-15
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-428127
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3742
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,840.74 of $2,500.0074%
- Out-of-pocket maximum
- $2,802.41 of $10,000.0028%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1717512853
- Network
- In network
- Rendering NPI
- 1717512853
- Location
- Atlanta, GA · TIN 95-9962981
- Authorisation / referral
- none / REF889296
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 | 59 | 1 | 1 | $59.00 | $36.58 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1,2 | $42.00 | $26.04 | — | — | Review |
| Totals | $101.00 | $62.62 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-604441
- 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-001651 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-30: CORE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 7 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 Heritage Clinical Laboratories (1717512853). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Heritage Clinical Laboratories2025-12-30 12:55
Patient seen for urinary tract infection, site not specified. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-06 03:21
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-06 10:35
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-604441.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:15The claim includes a lipid panel and a comprehensive metabolic panel, both billed with modifier 59, which indicates separate procedures. However, the clinical note [N1] and the operative note in the medical record [A1] both state that the procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, which is only acceptable when the record documents a distinct anatomical site or separate session. Therefore, the claim is denied with reason code CO97, as the procedures are considered bundled and not separately payable.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · a280e045
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes a lipid panel and a comprehensive metabolic panel, both billed with modifier 59, which indicates separate procedures. However, the clinical note [N1] and the operative note in the medical record [A1] both state that the procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, which is only acceptable when the record documents a distinct anatomical site or separate session. Therefore, the claim is denied with reason code CO97, as the procedures are considered bundled and not separately payable.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.