CLM-2026-033540
Lakeside Reference Lab, Clinical Laboratory. Service 2026-02-18 at independent laboratory (POS 81). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Raymond Walker
- Member ID
- UHC-50610-35
- Date of birth
- 2005-07-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400829
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5271
- Coverage period
- 2024-07-01 to present
- Deductible
- $114.14 of $1,500.008%
- Out-of-pocket maximum
- $753.59 of $3,000.0025%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8593662793
- Network
- In network
- Rendering NPI
- 8593662793
- Location
- Austin, TX · TIN 19-8347023
- Authorisation / referral
- none / REF289576
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 | — | 1 | 1 | $60.00 | $37.20 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| Totals | $97.00 | $60.14 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-279606
- 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-015059 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-18: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 34 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 Lakeside Reference Lab (8593662793). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Reference Lab2026-02-18 11:18
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-24 03:55
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-24 17:34
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.