CLM-2026-029529
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-05-17 at independent laboratory (POS 81). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- Diane Meyer
- Member ID
- UHC-37316-71
- Date of birth
- 1984-01-08
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-417723
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5094
- Coverage period
- 2024-05-01 to 2026-02-20
- Deductible
- $89.79 of $3,500.003%
- Out-of-pocket maximum
- $1,822.89 of $7,000.0026%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 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 / 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 | $62.00 | $38.44 | — | — | DeniedCO27 |
| Totals | $62.00 | $38.44 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-283789
- 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-025942 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-17 is after coverage terminated on 2026-02-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 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 Laboratories2026-05-17 12:08
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-05-21 04:34
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-21 09:55
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 2026-05-17 is after coverage terminated on 2026-02-20.
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.