CLM-2026-032491
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-07-31 at independent laboratory (POS 81). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Sofia Arnold
- Member ID
- UHC-41265-38
- Date of birth
- 1973-09-13
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-427647
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1212
- Coverage period
- 2025-04-01 to present
- Deductible
- $262.06 of $500.0052%
- Out-of-pocket maximum
- $483.36 of $1,000.0048%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 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 / REF264493
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 | $56.00 | $25.20 | — | — | DeniedCO204 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1 | $38.00 | $17.10 | — | — | DeniedCO204 |
| 3 | 80061 | Lipid panel | 25 | 1 | 2 | $50.00 | $22.50 | — | — | DeniedCO204 |
| 4 | 87086 | Urine culture | — | 1 | 1 | $36.00 | $16.20 | — | — | DeniedCO204 |
| Totals | $180.00 | $81.00 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-233017
- 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-020867 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-31: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 33 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 Laboratories2026-07-31 12:58
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-02 01:31
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 engineDenied2026-10-22 12:44Provider 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-2026-019427 | 2026-05-28 | Mesa Dermatology Clinic | $418.00 | Approved |
| CLM-2026-012495 | 2026-03-10 | Riverside Primary Care Associates | $46.00 | 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.