CLM-2026-033739
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-09-13 at independent laboratory (POS 81). Received 2026-09-18.
Member
Resolved through the identity graph
- Member
- Jack Ortiz
- Member ID
- UHC-23081-51
- Date of birth
- 1957-12-15
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-405614
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1451
- Coverage period
- 2024-02-01 to 2026-07-17
- Deductible
- $966.43 of $1,500.0064%
- Out-of-pocket maximum
- $2,005.74 of $4,500.0045%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4740334576
- Network
- In network
- Rendering NPI
- 4740334576
- Location
- Mesa, AZ · TIN 57-0560500
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $51.00 | $31.62 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $75.00 | $46.50 | — | — | DeniedCO27 |
| Totals | $126.00 | $78.12 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-643444
- 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-020197 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-13 is after coverage terminated on 2026-07-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Cornerstone Reference Lab (4740334576). | |
| 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: Cornerstone Reference Lab2026-09-13 11:03
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-18 00:24
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-18 17:42
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 2026-09-13 is after coverage terminated on 2026-07-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019648 | 2026-03-11 | Desert Imaging Center | $2,259.00 | 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.