CLM-2026-028342
Evergreen Reference Lab, Clinical Laboratory. Service 2026-07-16 at independent laboratory (POS 81). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Patricia Flores
- Member ID
- none on golden record
- Date of birth
- 1940-05-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-419445
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-9137
- Coverage period
- 2024-12-01 to 2026-01-24
- Deductible
- $224.12 of $500.0045%
- Out-of-pocket maximum
- $227.01 of $1,000.0023%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- Authorisation / referral
- none / REF176452
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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $54.00 | $33.48 | — | — | DeniedCO27 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $57.00 | $35.34 | — | — | DeniedCO27 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 2 | $50.00 | $31.00 | — | — | DeniedCO27 |
| Totals | $161.00 | $99.82 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-838952
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000877; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-07-16 is after coverage terminated on 2026-01-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 Evergreen Reference Lab (6979403576). | |
| 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: Evergreen Reference Lab2026-07-16 18:26
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-30 06:15
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-30 17:23
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 engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000877; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-07-16 is after coverage terminated on 2026-01-24.
Other claims for this member
Same resolved identity
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.