CLM-2026-027676
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-07-27 at independent laboratory (POS 81). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Fatima Jacobs
- Member ID
- UHC-41356-33
- Date of birth
- 1974-02-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-432225
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2189
- Coverage period
- 2022-08-01 to 2026-01-23
- Deductible
- $253.09 of $2,500.0010%
- Out-of-pocket maximum
- $161.44 of $10,000.002%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7665709730
- Network
- In network
- Rendering NPI
- 7665709730
- Location
- Mesa, AZ · TIN 27-4199484
- 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 | 87086 | Urine culture | — | 1 | 1 | $64.00 | $39.68 | — | — | DeniedCO27 |
| Totals | $64.00 | $39.68 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-811244
- 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-006607 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-27 is after coverage terminated on 2026-01-23. Expenses incurred after coverage terminated |
| 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 Summit Clinical Laboratories (7665709730). | |
| 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: Summit Clinical Laboratories2026-07-27 14:43
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-08-03 03:40
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-03 14:42
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-27 is after coverage terminated on 2026-01-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012960 | 2026-05-30 | Valley Medical Group | $402.00 | Denied |
| CLM-2026-033286 | 2026-05-21 | Pinecrest Medical Group | $303.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.