Professional claim · CMS-1500 · Paper
CLM-2026-001559
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-03-03 at independent laboratory (POS 81). Received 2026-03-24.
ApprovedOut of network
Billed
$177.00
3 lines
Allowed
$79.65
contract rate applied
Plan pays
$0.00
approved
Member owes
$79.65
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Kathleen Gibson
- Member ID
- UHC-89929-38
- Date of birth
- 2007-07-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403075
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6274
- Coverage period
- 2021-12-01 to present
- Deductible
- $869.14 of $1,000.0087%
- Out-of-pocket maximum
- $1,060.96 of $3,000.0035%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | 80061 | Lipid panel | — | 1 | 1 | $42.00 | $18.90 | $18.90 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1,2 | $85.00 | $38.25 | $38.25 | $0.00 | Paid |
| 3 | 87086 | Urine culture | — | 1 | 2 | $50.00 | $22.50 | $22.50 | $0.00 | Paid |
| Totals | $177.00 | $79.65 | $79.65 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-251375
- 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-011542 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-03: MEDICARE-ADV-A (MA), effective 2021-12-01. | |
| Timely filing | Pass | Received 21 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Reference Lab2026-03-03 13:57
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$177.00
Plan discount
$97.35
out-of-network allowance
Plan paid
$0.00
You may owe
$79.65
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017103 | 2026-07-26 | Unity Bone and Joint Center | $34,571.00 | Needs review |
| CLM-2026-001560 | 2026-03-03 | Cornerstone Reference Lab | $177.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.