CLM-2026-033432
Pinecrest Clinical Laboratories, Clinical Laboratory. Service 2026-04-28 at independent laboratory (POS 81). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Eric Castro
- Member ID
- UHC-08239-66
- Date of birth
- 1968-04-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408475
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8348
- Coverage period
- 2023-10-01 to 2026-04-20
- Deductible
- $1,515.32 of $2,500.0061%
- Out-of-pocket maximum
- $3,233.62 of $7,500.0043%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6068288409
- Network
- In network
- Rendering NPI
- 6068288409
- Location
- San Diego, CA · TIN 41-0079440
- Authorisation / referral
- none / REF100941
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 | $43.40 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $54.00 | $33.48 | — | — | DeniedCO27 |
| Totals | $124.00 | $76.88 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-417314
- 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-004267 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-28 is after coverage terminated on 2026-04-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 Clinical Laboratories (6068288409). | |
| 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: Pinecrest Clinical Laboratories2026-04-28 16:54
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-02 03:18
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-02 14:53
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-28 is after coverage terminated on 2026-04-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025371 | 2026-05-01 | Sunrise Imaging Center | $410.00 | Denied |
| CLM-2026-015676 | 2026-03-07 | Desert Internal Medicine Associates | $323.00 | Approved |
| CLM-2026-030356 | 2025-12-28 | Riverside Digestive Health Center | $2,012.00 | 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
Service after coverage termination.