CLM-2026-029441
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-05-27 at independent laboratory (POS 81). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Ahmed Silva
- Member ID
- UHC-49438-05
- Date of birth
- 1965-07-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418510
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9249
- Coverage period
- 2024-01-01 to present
- Deductible
- $256.83 of $500.0051%
- Out-of-pocket maximum
- $166.64 of $1,500.0011%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7837946178
- Network
- In network
- Rendering NPI
- 7837946178
- Location
- Miami, FL · TIN 25-9657303
- Authorisation / referral
- none / REF278137
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 | 80061 | Lipid panel | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO18 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $65.00 | $40.30 | — | — | DeniedCO18 |
| Totals | $114.00 | $70.68 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-341362
- 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-017185 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-029440: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Clinical Laboratories (7837946178). | |
| 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: Mesa Clinical Laboratories2026-05-27 10:45
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-24 00:13
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-24 11:22
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 12:44Duplicate check: Exact duplicate of CLM-2026-029440: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025394 | 2026-06-08 | Harbor Reference Lab | $41.00 | Approved |
| CLM-2026-029440 | 2026-05-27 | Mesa Clinical Laboratories | $114.00 | Approved |
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
Exact duplicate of an earlier submission.