CLM-2026-028577
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-02-23 at independent laboratory (POS 81). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Donald Reyes
- Member ID
- UHC-95264-09
- Date of birth
- 1991-06-19
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419044
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1946
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,680.36 of $3,500.0048%
- Out-of-pocket maximum
- $4,379.93 of $10,500.0042%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4658545775
- Network
- In network
- Rendering NPI
- 4658545775
- Location
- Nashville, TN · TIN 46-3944413
- 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 | — | 1 | 1 | $36.00 | $22.32 | — | — | Review |
| 2 | 87086 | Urine culture | — | 1 | 1 | $68.00 | $42.16 | — | — | Review |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $55.00 | $34.10 | — | — | Review |
| Totals | $159.00 | $98.58 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-839057
- 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-013630 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-23: CHOICE-PLUS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 23 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 (4658545775). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Clinical Laboratories2026-02-23 11:23
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-18 06:09
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-18 16:21
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
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
Development letter outstanding.