CLM-2026-002193
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-08-23 at independent laboratory (POS 81). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Logan Payne
- Member ID
- UHC-81447-44
- Date of birth
- 1986-04-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429892
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0549
- Coverage period
- 2025-02-01 to present
- Deductible
- $887.75 of $3,500.0025%
- Out-of-pocket maximum
- $1,960.42 of $14,000.0014%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7794266271
- Network
- In network
- Rendering NPI
- 7794266271
- Location
- Austin, TX · TIN 55-3185776
- Authorisation / referral
- none / REF650243
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 | $50.00 | $31.00 | — | — | DeniedCO18 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $61.00 | $37.82 | — | — | DeniedCO18 |
| Totals | $111.00 | $68.82 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-985163
- 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-017837 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-23: NAVIGATE-HMO (HMO), effective 2025-02-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002192: 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 (7794266271). | |
| 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 Laboratories2026-08-23 10:46
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-09-19 04:41
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-19 16:20
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-002192: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002192 | 2026-08-23 | Sunrise Clinical Laboratories | $111.00 | Approved |
| CLM-2026-032493 | 2026-05-31 | Harbor Primary Care Associates | $19.00 | 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.