CLM-2026-033246
Valley Clinical Laboratories, Clinical Laboratory. Service 2026-02-02 at independent laboratory (POS 81). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Walter Gray
- Member ID
- UHC-31744-18
- Date of birth
- 1982-03-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-417631
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group UNKNOWN
- Coverage period
- 2022-07-01 to present
- Deductible
- $79.13 of $500.0016%
- Out-of-pocket maximum
- $496.32 of $2,000.0025%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 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 / REF886613
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 | 87086 | Urine culture | — | 1 | 1 | $70.00 | $31.50 | — | — | DeniedCO204 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $81.00 | $36.45 | — | — | DeniedCO204 |
| Totals | $151.00 | $67.95 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-423681
- 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-013670 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-02: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 40 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 Laboratories2026-02-02 15:23
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-03-14 00:03
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 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-2026-025284 | 2026-02-07 | Valley Medical Group | $214.00 | 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.