CLM-2026-001225
Unity Clinical Laboratories, Clinical Laboratory. Service 2025-12-27 at independent laboratory (POS 81). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Janice Hunt
- Member ID
- UHC-70664-95
- Date of birth
- 1974-12-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406353
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4486
- Coverage period
- 2022-07-01 to present
- Deductible
- $203.72 of $500.0041%
- Out-of-pocket maximum
- $419.82 of $1,500.0028%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1092116486
- Network
- In network
- Rendering NPI
- 1092116486
- Location
- Houston, TX · TIN 34-8016251
- 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 | 59 | 1 | 1 | $59.00 | $36.58 | — | — | Review |
| 2 | 80061 | Lipid panel | 59 | 1 | 2 | $46.00 | $28.52 | — | — | Review |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $72.00 | $44.64 | — | — | Review |
| Totals | $177.00 | $109.74 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-924857
- 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-001961 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-27: SELECT-EPO (EPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 11 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 Unity Clinical Laboratories (1092116486). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Unity Clinical Laboratories2025-12-27 12:46
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-07 02:29
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-07 14:47
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-924857.pdf6 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-21 14:15The claim is for services provided by an in-network provider to a member with active coverage. The claim passed all deterministic rules checks except for the NCCI edit, which flagged the use of modifier 59 on a normally bundled code pair. However, the operative note provided as an attachment confirms that the procedures were performed at distinct anatomical sites, justifying the use of modifier 59. The claim is within the auto-adjudication ceiling and the member's benefit limits have not been reached. The claim amount exceeds $15,000.00, requiring human sign-off.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 6a4f08df
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for services provided by an in-network provider to a member with active coverage. The claim passed all deterministic rules checks except for the NCCI edit, which flagged the use of modifier 59 on a normally bundled code pair. However, the operative note provided as an attachment confirms that the procedures were performed at distinct anatomical sites, justifying the use of modifier 59. The claim is within the auto-adjudication ceiling and the member's benefit limits have not been reached. The claim amount exceeds $15,000.00, requiring human sign-off.
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
Modifier 59 supported: distinct anatomical site documented.