Professional claim · CMS-1500 · Paper
CLM-2026-033813
Mesa Reference Lab, Clinical Laboratory. Service 2026-05-31 at independent laboratory (POS 81). Received 2026-06-28.
Denied
Billed
$110.00
2 lines
Allowed
$68.20
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Abigail McDonald
- Member ID
- UHC-91015-76
- Date of birth
- 1969-07-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403454
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6616
- Coverage period
- 2024-10-01 to 2026-01-28
- Deductible
- $474.79 of $1,500.0032%
- Out-of-pocket maximum
- $821.19 of $4,500.0018%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1578442364
- Network
- In network
- Rendering NPI
- 1578442364
- Location
- Scottsdale, AZ · TIN 27-6614149
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $61.00 | $37.82 | — | — | DeniedCO27 |
| Totals | $110.00 | $68.20 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
Claim header
- Patient account
- PA-861041
- 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-025474 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-31 is after coverage terminated on 2026-01-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 Reference Lab (1578442364). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Reference Lab2026-05-31 11:05
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-28 03:26
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-31 is after coverage terminated on 2026-01-28.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000912 | 2026-05-10 | Lakeside Bone and Joint Center | $7,162.00 | Denied |
| CLM-2026-020780 | 2026-03-18 | Summit Primary Care Associates | $212.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.