CLM-2026-030880
Evergreen Reference Lab, Clinical Laboratory. Service 2026-04-13 at independent laboratory (POS 81). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Donald Williamon
- Member ID
- UHC-85616-98
- Date of birth
- 1972-09-21
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-409120
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9509
- Coverage period
- 2025-04-01 to present
- Deductible
- $275.51 of $1,500.0018%
- Out-of-pocket maximum
- $711.48 of $6,000.0012%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- Authorisation / referral
- none / REF112689
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 | 87086 | Urine culture | 59 | 1 | 1 | $32.00 | $19.84 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 2 | $49.00 | $30.38 | — | — | Review |
| Totals | $81.00 | $50.22 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-835501
- 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-012327 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-13: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 25 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 Evergreen Reference Lab (6979403576). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Evergreen Reference Lab2026-04-13 10:18
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-05-08 05:03
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-835501.pdf4 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.