CLM-2026-001300
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-05-19 at independent laboratory (POS 81). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Theresa Tucker
- Member ID
- UHC-63388-86
- Date of birth
- 1972-03-03
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-420155
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5847
- Coverage period
- 2022-09-01 to present
- Deductible
- $202.23 of $1,500.0013%
- Out-of-pocket maximum
- $1,269.79 of $6,000.0021%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- 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 | $42.00 | $26.04 | — | — | DeniedCO18 |
| Totals | $42.00 | $26.04 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-518063
- 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-019489 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-05-19: MEDICARE-ADV-B (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-001299: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Clinical Laboratories (1737179139). | |
| 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: Sunrise Clinical Laboratories2026-05-19 17:53
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-14 06:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-14 12:32
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-001299: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001299 | 2026-05-19 | Sunrise Clinical Laboratories | $42.00 | Approved |
| CLM-2026-031275 | 2026-02-06 | Unity Physical Therapy | $426.00 | 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
Exact duplicate of an earlier submission.