CLM-2026-032404
Valley Clinical Laboratories, Clinical Laboratory. Service 2026-01-07 at independent laboratory (POS 81). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Madison Montgomery
- Member ID
- UHC-92303-01
- Date of birth
- 1976-10-17
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-405508
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4278
- Coverage period
- 2024-02-01 to present
- Deductible
- $157.36 of $500.0031%
- Out-of-pocket maximum
- $404.50 of $1,000.0040%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5408693625
- Network
- Out of network
- Rendering NPI
- 5408693625
- Location
- Tampa, FL · TIN 43-5217451
- Authorisation / referral
- none / REF784481
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 | $38.00 | $17.10 | — | — | DeniedCO204 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 2 | $66.00 | $29.70 | — | — | DeniedCO204 |
| Totals | $104.00 | $46.80 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-409352
- 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-006584 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-07: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 25 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 5408693625 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: Valley Clinical Laboratories2026-01-07 10:40
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-01 06:58
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
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 5408693625 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-2026-015646 | 2026-07-29 | Unity Clinical Laboratories | $113.00 | Approved |
| CLM-2026-001567 | 2026-03-19 | Cornerstone Orthopedic Specialists | $244.00 | 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
No out-of-network benefit on this plan.