CLM-2026-032017
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-07-14 at independent laboratory (POS 81). Received 2026-08-05.
Member
Resolved through the identity graph
- Member
- Jack Yang
- Member ID
- UHC-59751-23
- Date of birth
- 1943-06-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428617
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8339
- Coverage period
- 2023-10-01 to present
- Deductible
- $437.80 of $500.0088%
- Out-of-pocket maximum
- $604.85 of $1,500.0040%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2122435433
- Network
- Out of network
- Rendering NPI
- 2122435433
- Location
- Los Angeles, CA · TIN 12-4722693
- Authorisation / referral
- none / REF488333
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 | 80061 | Lipid panel | — | 1 | 1 | $57.00 | $25.65 | — | — | DeniedCO204 |
| Totals | $57.00 | $25.65 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-974954
- 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-000048 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-14: NAVIGATE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 22 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 | Fail | CO204 | Billing provider 2122435433 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Harbor Clinical Laboratories2026-07-14 15:25
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-05 06:43
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-05 15:14
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 13:43Provider network: Billing provider 2122435433 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001075 | 2026-04-10 | Riverside GI Associates | $1,424.00 | Approved |
| CLM-2026-002280 | 2025-12-14 | Sunrise Clinical Laboratories | $231.00 | 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
No out-of-network benefit on this plan.