CLM-2026-030767
Desert Reference Lab, Clinical Laboratory. Service 2026-07-01 at independent laboratory (POS 81). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Angela Hawkins
- Member ID
- UHC-27048-49
- Date of birth
- 2003-04-13
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-409545
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6218
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,024.59 of $2,500.0081%
- Out-of-pocket maximum
- $2,345.47 of $5,000.0047%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8770600343
- Network
- In network
- Rendering NPI
- 8770600343
- Location
- Charlotte, NC · TIN 95-8427409
- 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 | $60.00 | $37.20 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1,2 | $37.00 | $22.94 | — | — | DeniedCO18 |
| Totals | $97.00 | $60.14 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-139514
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034617 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-07-01: MEDICARE-ADV-B (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030766: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Reference Lab (8770600343). | |
| 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: Desert Reference Lab2026-07-01 10:10
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-23 00:33
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-030766: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030766 | 2026-07-01 | Desert Reference Lab | $97.00 | Approved |
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
Exact duplicate of an earlier submission.