CLM-2026-029554
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-02-12 at independent laboratory (POS 81). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Jacob Coleman
- Member ID
- UHC-36389-70
- Date of birth
- 1952-08-26
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-429547
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5908
- Coverage period
- 2022-03-01 to present
- Deductible
- $1,325.10 of $1,500.0088%
- Out-of-pocket maximum
- $1,031.90 of $6,000.0017%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2023964945
- Network
- Out of network
- Rendering NPI
- 2023964945
- Location
- Atlanta, GA · TIN 12-9444799
- 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 | $54.00 | $24.30 | $24.30 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $83.00 | $37.35 | $37.35 | $0.00 | Paid |
| Totals | $137.00 | $61.65 | $61.65 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-795882
- 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-007509 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-12: CHOICE-PLUS-PPO (PPO), effective 2022-03-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Laboratories2026-02-12 10:51
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009155 | 2026-08-11 | Harbor Medical Group | $257.00 | Approved |
| CLM-2026-015258 | 2026-03-02 | Riverside Digestive Health Center | $3,774.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.