CLM-2026-032001
Desert Reference Lab, Clinical Laboratory. Service 2025-11-15 at independent laboratory (POS 81). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Roy James
- Member ID
- UHC-07344-39
- Date of birth
- 2008-11-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431848
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7736
- Coverage period
- 2024-08-01 to present
- Deductible
- $992.01 of $1,500.0066%
- Out-of-pocket maximum
- $645.05 of $3,000.0022%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 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 / REF698398
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 | $81.00 | $50.22 | — | — | DeniedCO29 |
| Totals | $81.00 | $50.22 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-487067
- 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-007895 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-15: CORE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Fail | CO29 | Received 195 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 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 Lab2025-11-15 15:18
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-29 06:20
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-29 16:07
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 engineDenied2026-10-22 12:44Timely filing: Received 195 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006843 | 2026-01-09 | Valley Skin Care Associates | $698.00 | Needs review |
| CLM-2026-006842 | 2026-01-09 | Valley Skin Care Associates | $698.00 | 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
Received after the timely-filing limit.