CLM-2026-033972
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-08-23 at independent laboratory (POS 81). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Jeremy Garrett
- Member ID
- UHC-79001-22
- Date of birth
- 1946-10-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431230
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7096
- Coverage period
- 2025-12-01 to present
- Deductible
- $182.35 of $500.0036%
- Out-of-pocket maximum
- $138.28 of $1,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 8920689386
- Network
- In network
- Rendering NPI
- 8920689386
- Location
- Mesa, AZ · TIN 50-3391688
- 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 | $58.00 | $35.96 | — | — | Review |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $38.00 | $23.56 | — | — | Review |
| Totals | $96.00 | $59.52 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-153285
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018729 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-23: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| 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 Clinical Laboratories (8920689386). | |
| 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 Clinical Laboratories2026-08-23 13:50
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-26 02:48
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-26 13:15
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005605 | 2026-03-08 | Northgate Orthopedic Specialists | $10,241.00 | Needs review |
| CLM-2026-005604 | 2026-03-08 | Northgate Orthopedic Specialists | $10,241.00 | Approved |
| CLM-2026-010530 | 2026-03-03 | Harbor Family Practice | $532.00 | Approved |
| CLM-2026-016077 | 2026-02-11 | Mesa Internal Medicine Associates | $354.00 | Approved |
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.