CLM-2026-027398
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-03-04 at independent laboratory (POS 81). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Nicole Le
- Member ID
- UHC-97923-15
- Date of birth
- 1987-04-18
- Identity
- Verified4 records, confidence 0.89
- Claim record
- CLMCLM-429763
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1746
- Coverage period
- 2024-02-01 to present
- Deductible
- $383.02 of $1,000.0038%
- Out-of-pocket maximum
- $707.30 of $2,000.0035%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 8920689386
- Network
- In network
- Rendering NPI
- 8920689386
- Location
- Mesa, AZ · TIN 50-3391688
- Authorisation / referral
- none / REF205860
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 | — | 1 | 1 | $69.00 | $42.78 | $42.78 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $56.00 | $34.72 | $34.72 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| Totals | $186.00 | $115.32 | $115.32 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-513857
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020070 (verified, link confidence 0.89). | |
| Eligibility | Pass | Active on 2026-03-04: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 38 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 Lakeside Clinical Laboratories (8920689386). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Clinical Laboratories2026-03-04 10:37
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031939 | 2026-04-26 | Northgate Clinical Laboratories | $198.00 | Approved |
| CLM-2026-019089 | 2025-11-24 | Harbor Medical Group | $147.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.