CLM-2026-031738
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-05-10 at independent laboratory (POS 81). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Katherine Bryant
- Member ID
- UHC-82369-83
- Date of birth
- 1946-11-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426766
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2077
- Coverage period
- 2024-05-01 to 2026-02-24
- Deductible
- $136.67 of $500.0027%
- Out-of-pocket maximum
- $29.23 of $1,000.003%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $54.00 | $24.30 | — | — | DeniedCO27 |
| Totals | $54.00 | $24.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-846747
- 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-035448 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-10 is after coverage terminated on 2026-02-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Reference Lab2026-05-10 18:19
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-24 02:53
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-10 is after coverage terminated on 2026-02-24. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025713 | 2026-05-07 | Sunrise Cardiovascular Associates | $312.00 | Denied |
| CLM-2026-019169 | 2026-06-03 | Cornerstone Internal Medicine Associates | $184.00 | 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
Service after coverage termination.