Claims workbench/CLM-2026-030736
Professional claim · CMS-1500 · Paper

CLM-2026-030736

Summit Reference Lab, Clinical Laboratory. Service 2026-08-25 at independent laboratory (POS 81). Received 2026-10-13.

Denied
Billed
$46.00
1 line
Allowed
$28.52
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Ethan Vazquez
Member ID
UHC-36033-31
Date of birth
1990-01-23
Identity
Verified5 records, confidence 1.00
Claim record
CLMCLM-403049
Relationship
Spouse, Orlando, FL

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-8245
Coverage period
2022-09-01 to present
Deductible
$1,039.62 of $1,500.0069%
Out-of-pocket maximum
$1,361.41 of $4,500.0030%
Copays
office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits
9 of 20 used

Provider

Billing and rendering

Billing provider
Summit Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI
2797853506
Network
In network
Rendering NPI
2797853506
Location
Nashville, TN · TIN 64-6425854
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180061Lipid panel—11$46.00$28.52——DeniedCO18
Totals$46.00$28.52——
Diagnoses (ICD-10-CM)
  • 1. N39.0 Urinary tract infection, site not specifiedprincipal
Claim header
Patient account
PA-440401
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-003530 (verified, link confidence 1.00).
EligibilityPassActive on 2026-08-25: SELECT-EPO (EPO), effective 2022-09-01.
Timely filingPassReceived 49 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-030735: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Reference Lab (2797853506).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Reference Lab2026-08-25 16:06

    Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-10-13 00:51

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

  • AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-13 11:23

    Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Duplicate check: Exact duplicate of CLM-2026-030735: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0307352026-08-25Summit Reference Lab$46.00Approved
CLM-2026-0136262026-08-09Valley Heart Institute$282.00Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity