CLM-2026-033695
Valley Reference Lab, Clinical Laboratory. Service 2026-02-15 at independent laboratory (POS 81). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Jose Gordon
- Member ID
- UHC-27613-60
- Date of birth
- 1994-04-13
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-423285
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5677
- Coverage period
- 2025-12-01 to present
- Deductible
- $133.99 of $3,500.004%
- Out-of-pocket maximum
- $1,045.47 of $7,000.0015%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8777376848
- Network
- In network
- Rendering NPI
- 8777376848
- Location
- Minneapolis, MN · TIN 45-5717570
- 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 | 87086 | Urine culture | — | 1 | 1 | $61.00 | $37.82 | — | — | DeniedCO29 |
| Totals | $61.00 | $37.82 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-197372
- 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-002618 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-15: OPTIONS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Fail | CO29 | Received 133 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Reference Lab (8777376848). | |
| 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 Reference Lab2026-02-15 13:53
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-28 01:45
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 133 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020795 | 2026-07-01 | Unity Imaging Center | $2,949.00 | Denied |
| CLM-2026-031149 | 2026-06-10 | Unity Counseling Center | $330.00 | 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
Received after the timely-filing limit.