CLM-2026-003310
Valley Reference Lab, Clinical Laboratory. Service 2026-01-30 at independent laboratory (POS 81). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Hiroshi Schultz
- Member ID
- UHC-49624-39
- Date of birth
- 1978-07-23
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422232
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0570
- Coverage period
- 2023-05-01 to present
- Deductible
- $563.36 of $1,500.0038%
- Out-of-pocket maximum
- $874.85 of $6,000.0015%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8777376848
- Network
- In network
- Rendering NPI
- 8777376848
- Location
- Minneapolis, MN · TIN 45-5717570
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $57.00 | $35.34 | $35.34 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $83.00 | $51.46 | $51.46 | $0.00 | Paid |
| Totals | $140.00 | $86.80 | $86.80 | $0.00 | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-408851
- 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-015745 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-30: NULL (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 39 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 Valley Reference Lab (8777376848). | |
| 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: Valley Reference Lab2026-01-30 12:26
Patient seen for urinary tract infection, site not specified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-10 00:42
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-408851.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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-2026-024560 | 2026-08-26 | Lakeside Bone and Joint Center | $36,744.00 | Needs review |
| CLM-2026-024559 | 2026-08-26 | Lakeside Bone and Joint Center | $36,744.00 | Needs review |
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
Authorisation must be confirmed with UM before payment.