CLM-2026-001339
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-04-30 at independent laboratory (POS 81). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Sophia Hall
- Member ID
- UHC-60987-96
- Date of birth
- 1942-01-17
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-431670
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9745
- Coverage period
- 2025-08-01 to 2026-04-11
- Deductible
- $114.59 of $1,000.0011%
- Out-of-pocket maximum
- $106.78 of $2,000.005%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $52.00 | $32.24 | — | — | DeniedCO27 |
| 3 | 87086 | Urine culture | — | 1 | 2 | $58.00 | $35.96 | — | — | DeniedCO27 |
| Totals | $173.00 | $107.26 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-217284
- 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-011791 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-30 is after coverage terminated on 2026-04-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 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 Laboratories2026-04-30 12:20
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-02 02:53
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 2026-04-30 is after coverage terminated on 2026-04-11.
Other claims for this member
Same resolved identity
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.