Claims workbench/CLM-2026-027264

Professional claim · CMS-1500 · EDI 837P

CLM-2026-027264

Summit Reference Lab, Clinical Laboratory. Service 2025-12-27 at independent laboratory (POS 81). Received 2026-02-08.

DeniedOut of network

Billed

$220.00

4 lines

Allowed

$99.00

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Gloria Washington
Member ID: UHC-94993-03
Date of birth: 1944-06-22
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-402629
Relationship: Spouse, Miami, FL

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-9890
Coverage period: 2024-03-01 to present
Deductible: $753.04 of $1,000.0075%
Out-of-pocket maximum: $587.03 of $3,000.0020%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 8 of 20 used

Provider

Billing and rendering

Billing provider: Summit Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI: 7256801888
Network: Out of network
Rendering NPI: 7256801888
Location: Scottsdale, AZ · TIN 41-8218808
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	85025	Complete blood count with differential	59	1	1	$68.00	$30.60	—	—	DeniedCO204
2	80053	Comprehensive metabolic panel	59	1	2	$67.00	$30.15	—	—	DeniedCO204
3	80061	Lipid panel	—	1	1	$37.00	$16.65	—	—	DeniedCO204
4	87086	Urine culture	—	1	2	$48.00	$21.60	—	—	DeniedCO204
Totals						$220.00	$99.00	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal

Claim header

Patient account: PA-928403
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-011511 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-27: SELECT-EPO (EPO), effective 2024-03-01.
Timely filing	Pass		Received 43 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 7256801888 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)	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.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Reference Lab2025-12-27 13:46
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-02-08 01:28
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-08 16:59
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Provider network: Billing provider 7256801888 is out of network and the EPO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

No other claims.

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity