CLM-2026-031602
Desert Reference Lab, Clinical Laboratory. Service 2026-04-17 at independent laboratory (POS 81). Received 2026-04-22.
Member
Resolved through the identity graph
- Member
- Martha Rodriguez
- Member ID
- UHC-02773-73
- Date of birth
- 1977-06-11
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-406250
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4456
- Coverage period
- 2025-01-01 to 2026-04-13
- Deductible
- $1,183.05 of $1,500.0079%
- Out-of-pocket maximum
- $2,432.62 of $6,000.0041%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5002077423
- Network
- In network
- Rendering NPI
- 5002077423
- Location
- Nashville, TN · TIN 21-2185658
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $73.00 | $45.26 | — | — | DeniedCO27 |
| Totals | $73.00 | $45.26 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-722243
- 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-000708 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-17 is after coverage terminated on 2026-04-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Desert Reference Lab (5002077423). | |
| 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 Lab2026-04-17 15:01
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-22 03:07
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-22 11:27
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-17 is after coverage terminated on 2026-04-13.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003367 | 2026-03-10 | Meadow Diagnostic Imaging | $1,305.00 | Approved |
| CLM-2026-026819 | 2026-02-19 | Cornerstone Imaging Center | $2,889.00 | Approved |
| CLM-2026-033423 | 2025-12-13 | Heritage Family Practice | $575.00 | 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
Service after coverage termination.