CLM-2026-030506
Heritage Clinical Laboratories, Clinical Laboratory. Service 2026-01-11 at independent laboratory (POS 81). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Luis Kelley
- Member ID
- UHC-64251-59
- Date of birth
- 1998-05-21
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-425767
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2541
- Coverage period
- 2025-02-01 to 2026-01-04
- Deductible
- $119.44 of $3,500.003%
- Out-of-pocket maximum
- $426.75 of $10,500.004%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1717512853
- Network
- In network
- Rendering NPI
- 1717512853
- Location
- Atlanta, GA · TIN 95-9962981
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $43.00 | $26.66 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $76.00 | $47.12 | — | — | DeniedCO27 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $34.00 | $21.08 | — | — | DeniedCO27 |
| Totals | $153.00 | $94.86 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-823058
- 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-011624 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-11 is after coverage terminated on 2026-01-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 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 Heritage Clinical Laboratories (1717512853). | |
| 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: Heritage Clinical Laboratories2026-01-11 13:05
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-09 05:16
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-09 09:34
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-01-11 is after coverage terminated on 2026-01-04.
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.