CLM-2026-027267
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-05-24 at independent laboratory (POS 81). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Jeffrey Cook
- Member ID
- UHC-82233-70
- Date of birth
- 1991-07-02
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-403176
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7716
- Coverage period
- 2025-12-01 to present
- Deductible
- $51.20 of $1,000.005%
- Out-of-pocket maximum
- $870.64 of $4,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7688028761
- Network
- In network
- Rendering NPI
- 7688028761
- Location
- Los Angeles, CA · TIN 67-3598965
- Authorisation / referral
- none / REF727447
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 | 87086 | Urine culture | 59 | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1,2 | $73.00 | $45.26 | — | — | Review |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 2 | $60.00 | $37.20 | — | — | Review |
| Totals | $170.00 | $105.40 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-210996
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019065 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-24: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 17 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 Summit Clinical Laboratories (7688028761). | |
| 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: Summit Clinical Laboratories2026-05-24 14:57
Patient seen for type 2 diabetes mellitus without complications. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-06-10 04:00
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-210996.pdf4 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 engineReview2026-10-22 12:44Bundling (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
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
Bundled code pair; modifier 59 not supported by the operative note.