CLM-2026-031766
Desert Clinical Laboratories, Clinical Laboratory. Service 2026-06-01 at independent laboratory (POS 81). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Brittany Schmidt
- Member ID
- UHC-24552-67
- Date of birth
- 1942-06-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423568
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7978
- Coverage period
- 2025-08-01 to present
- Deductible
- $554.89 of $3,500.0016%
- Out-of-pocket maximum
- $4,615.94 of $10,500.0044%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9068366761
- Network
- In network
- Rendering NPI
- 9068366761
- Location
- Houston, TX · TIN 28-8573609
- Authorisation / referral
- none / REF296991
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 | $55.00 | $34.10 | — | — | DeniedCO29 |
| Totals | $55.00 | $34.10 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-727717
- 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-043440 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-01: CORE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Fail | CO29 | Received 96 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 Desert Clinical Laboratories (9068366761). | |
| 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 Clinical Laboratories2026-06-01 09:50
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-05 06:30
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-05 12:05
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 96 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.