CLM-2026-031341
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-04-13 at independent laboratory (POS 81). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Danielle Ellis
- Member ID
- UHC-82998-58
- Date of birth
- 1990-10-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405370
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group UNKNOWN
- Coverage period
- 2025-05-01 to present
- Deductible
- $362.18 of $1,000.0036%
- Out-of-pocket maximum
- $344.16 of $4,000.009%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5775545838
- Network
- In network
- Rendering NPI
- 5775545838
- Location
- Miami, FL · TIN 91-7135882
- Authorisation / referral
- none / REF413639
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 | $52.00 | $32.24 | — | — | DeniedCO29 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $79.00 | $48.98 | — | — | DeniedCO29 |
| Totals | $131.00 | $81.22 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-193857
- 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-028217 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-13: CORE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Fail | CO29 | Received 130 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Clinical Laboratories (5775545838). | |
| 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: Meadow Clinical Laboratories2026-04-13 18:10
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-08-21 06:50
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 130 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026953 | 2026-05-10 | Lakeside Medical Group | $804.00 | Denied |
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
Received after the timely-filing limit.