Claims workbench/CLM-2026-033126

Professional claim · CMS-1500 · Paper

CLM-2026-033126

Pinecrest Reference Lab, Clinical Laboratory. Service 2026-04-21 at independent laboratory (POS 81). Received 2026-04-25.

Needs review

Billed

$107.00

2 lines

Allowed

$66.34

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Jacob Burns
Member ID: UHC-30689-30
Date of birth: 1948-11-14
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-415014
Relationship: Self, Atlanta, GA

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-8035
Coverage period: 2024-06-01 to present
Deductible: $301.39 of $500.0060%
Out-of-pocket maximum: $86.91 of $1,000.009%
Copays: office $40.00, specialist $40.00, emergency $150.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI: 4399070182
Network: In network
Rendering NPI: 4399070182
Location: Houston, TX · TIN 93-0870375
Authorisation / referral: none / none

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	85025	Complete blood count with differential	59	1	1	$68.00	$42.16	—	—	Review
2	80061	Lipid panel	59	1	1	$39.00	$24.18	—	—	Review
Totals						$107.00	$66.34	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
2. N39.0 Urinary tract infection, site not specified

Claim header

Patient account: PA-720546
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-027705 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-04-21: SELECT-EPO (EPO), effective 2024-06-01.
Timely filing	Pass		Received 4 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	Pass		In-network provider Pinecrest Reference Lab (4399070182).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Reference Lab2026-04-21 15:35
Patient seen for type 2 diabetes mellitus without complications. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-04-25 01:41
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-25 10:24
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Medical recordrecords_PA-720546.pdf13 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-031134	2026-04-07	Valley Medical Group	$318.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity