CLM-2026-001577
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-05-24 at independent laboratory (POS 81). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Deborah Bishop
- Member ID
- UHC-53289-31
- Date of birth
- 1961-04-12
- Identity
- Verified3 records, confidence 0.85
- Claim record
- CLMCLM-403812
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4378
- Coverage period
- 2025-10-01 to present
- Deductible
- $205.82 of $500.0041%
- Out-of-pocket maximum
- $17.56 of $1,000.002%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3912329836
- Network
- In network
- Rendering NPI
- 3912329836
- Location
- Nashville, TN · TIN 38-7470413
- 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 | $52.00 | $32.24 | $32.24 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $43.00 | $26.66 | $26.66 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $63.00 | $39.06 | $39.06 | $0.00 | Paid |
| Totals | $158.00 | $97.96 | $97.96 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-253691
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022384 (verified, link confidence 0.85). | |
| Eligibility | Pass | Active on 2026-05-24: OPTIONS-PPO (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 16 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 Summit Clinical Laboratories (3912329836). | |
| 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: Summit Clinical Laboratories2026-05-24 11:30
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001578 | 2026-05-24 | Summit Clinical Laboratories | $158.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.