CLM-2026-033361
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-07-23 at independent laboratory (POS 81). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Douglas Kim
- Member ID
- UHC-49616-13
- Date of birth
- 1940-07-09
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-422933
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9908
- Coverage period
- 2025-05-01 to 2026-05-22
- Deductible
- $452.10 of $2,500.0018%
- Out-of-pocket maximum
- $966.99 of $7,500.0013%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7837946178
- Network
- In network
- Rendering NPI
- 7837946178
- Location
- Miami, FL · TIN 25-9657303
- Authorisation / referral
- none / REF634830
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 | $83.00 | $51.46 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $64.00 | $39.68 | — | — | DeniedCO27 |
| Totals | $147.00 | $91.14 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-785033
- 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-006054 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-23 is after coverage terminated on 2026-05-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 Mesa Clinical Laboratories (7837946178). | |
| 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: Mesa Clinical Laboratories2026-07-23 13:41
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-15 06:24
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-15 09:18
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-23 is after coverage terminated on 2026-05-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028562 | 2026-09-29 | Heritage Community Hospital | $1,664.00 | 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
Service after coverage termination.