CLM-2026-030886
Meadow Reference Lab, Clinical Laboratory. Service 2025-12-03 at independent laboratory (POS 81). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Rebecca Hernandez
- Member ID
- UHC-72721-98
- Date of birth
- 1991-06-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-407655
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0611
- Coverage period
- 2022-03-01 to present
- Deductible
- $187.84 of $500.0038%
- Out-of-pocket maximum
- $77.46 of $1,000.008%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 3840164321
- Network
- Out of network
- Rendering NPI
- 3840164321
- Location
- Los Angeles, CA · TIN 14-8564922
- 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 | $61.00 | $27.45 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $43.00 | $19.35 | — | — | Review |
| 3 | 87086 | Urine culture | — | 1 | 2 | $61.00 | $27.45 | — | — | Review |
| Totals | $165.00 | $74.25 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-709126
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002776 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-03: MEDICARE-ADV-B (MA), effective 2022-03-01. | |
| Timely filing | Pass | Received 37 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Reference Lab2025-12-03 14:07
Patient seen for urinary tract infection, site not specified. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-09 05:12
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-09 13:53
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 engineReview2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:42 · 40a54623
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030721 | 2026-04-22 | Harbor Clinical Laboratories | $149.00 | Approved |
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
Development letter outstanding.