CLM-2026-003905
Pinecrest Clinical Laboratories, Clinical Laboratory. Service 2026-01-18 at independent laboratory (POS 81). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Stephen Vasquez
- Member ID
- UHC-70906-85
- Date of birth
- 1957-08-23
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-400417
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-4414
- Coverage period
- 2025-11-01 to 2026-05-13
- Deductible
- $1,064.79 of $2,500.0043%
- Out-of-pocket maximum
- $2,188.92 of $10,000.0022%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6068288409
- Network
- In network
- Rendering NPI
- 6068288409
- Location
- San Diego, CA · TIN 41-0079440
- 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 | $38.00 | $23.56 | $23.56 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $69.00 | $42.78 | $42.78 | $0.00 | Paid |
| Totals | $107.00 | $66.34 | $66.34 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-900014
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004094 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-18: - (PPO), effective 2025-11-01, terms 2026-05-13. | |
| Timely filing | Pass | Received 42 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 Pinecrest Clinical Laboratories (6068288409). | |
| 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: Pinecrest Clinical Laboratories2026-01-18 16:55
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.