CLM-2026-032833
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-01-25 at independent laboratory (POS 81). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Jonathan Ortega
- Member ID
- UHC-09877-57
- Date of birth
- 1993-09-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411646
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6807
- Coverage period
- 2022-07-01 to present
- Deductible
- $559.13 of $2,500.0022%
- Out-of-pocket maximum
- $2,245.30 of $7,500.0030%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 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 / REF206408
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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $54.00 | $24.30 | — | — | DeniedCO204 |
| 2 | 87086 | Urine culture | — | 1 | 1 | $42.00 | $18.90 | — | — | DeniedCO204 |
| Totals | $96.00 | $43.20 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-809738
- 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-012716 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-25: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 19 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 Laboratories2026-01-25 17:01
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-13 01:27
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-13 13:33
Escalated to nurse reviewer for clinical opinion.
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-2026-008373 | 2026-09-02 | Sunrise Dermatology Clinic | $203.00 | Approved |
| CLM-2026-013996 | 2026-07-29 | Evergreen Family Practice | $158.00 | 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.