CLM-2026-029636
Valley Clinical Laboratories, Clinical Laboratory. Service 2026-06-06 at independent laboratory (POS 81). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Sean Shaw
- Member ID
- UHC-92556-56
- Date of birth
- 1971-12-01
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-410502
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2714
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,061.62 of $2,500.0042%
- Out-of-pocket maximum
- $3,908.43 of $10,000.0039%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5408693625
- Network
- Out of network
- Rendering NPI
- 5408693625
- Location
- Tampa, FL · TIN 43-5217451
- Authorisation / referral
- none / REF401724
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 | $38.00 | $17.10 | — | — | DeniedCO204 |
| 2 | 80061 | Lipid panel | 25 | 1 | 1 | $37.00 | $16.65 | — | — | DeniedCO204 |
| Totals | $75.00 | $33.75 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-359482
- 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-032855 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-06: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 19 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 | Fail | CO204 | Billing provider 5408693625 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Clinical Laboratories2026-06-06 17:31
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-25 03:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-25 11:30
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 12:44Provider network: Billing provider 5408693625 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.