CLM-2026-031976
Pinecrest Reference Lab, Clinical Laboratory. Service 2026-01-04 at independent laboratory (POS 81). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Shirley Lee
- Member ID
- UHC-25265-26
- Date of birth
- 2007-05-12
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-421757
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5829
- Coverage period
- 2024-03-01 to present
- Deductible
- $63.79 of $500.0013%
- Out-of-pocket maximum
- $582.02 of $2,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4399070182
- Network
- In network
- Rendering NPI
- 4399070182
- Location
- Houston, TX · TIN 93-0870375
- Authorisation / referral
- none / REF398886
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 | $30.00 | $18.60 | — | — | Review |
| Totals | $30.00 | $18.60 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-486038
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003043 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-04: CORE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-031975; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Reference Lab (4399070182). | |
| 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: Pinecrest Reference Lab2026-01-04 15:24
Patient seen for essential (primary) hypertension. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-17 01:42
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-17 10:12
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-031975.pdf1 page
Provider cover letter requesting replacement of CLM-2026-031975.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-031975; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-23 19:14This is a replacement claim [C] for a previously approved claim [H1]. The provider has corrected an error in the original submission [N1]. The member is eligible [R-eligibility], the provider is in-network [R-network], and the service is medically necessary [R-clinical_edit]. The claim is complete [R-completeness] and within the auto-adjudication ceiling [R-high_dollar]. The original claim must be voided when this one adjudicates [N2].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:14 · 694c17ab
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018204 | 2026-04-21 | Evergreen GI Associates | $3,316.00 | Approved |
| CLM-2026-031975 | 2026-01-04 | Pinecrest Reference Lab | $30.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim [C] for a previously approved claim [H1]. The provider has corrected an error in the original submission [N1]. The member is eligible [R-eligibility], the provider is in-network [R-network], and the service is medically necessary [R-clinical_edit]. The claim is complete [R-completeness] and within the auto-adjudication ceiling [R-high_dollar]. The original claim must be voided when this one adjudicates [N2].
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
Replacement claim supersedes the original.