CLM-2026-004061
Harbor Reference Lab, Clinical Laboratory. Service 2026-01-16 at independent laboratory (POS 81). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- Albert Smith
- Member ID
- UHC-58594-50
- Date of birth
- 1976-12-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412178
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6807
- Coverage period
- 2024-07-01 to present
- Deductible
- $289.05 of $1,000.0029%
- Out-of-pocket maximum
- $1,408.87 of $3,000.0047%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4121885428
- Network
- In network
- Rendering NPI
- 4121885428
- Location
- Tempe, AZ · TIN 21-1131562
- Authorisation / referral
- none / REF489292
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 | $45.00 | $27.90 | $27.90 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 2 | $55.00 | $34.10 | $34.10 | $0.00 | Paid |
| Totals | $100.00 | $62.00 | $62.00 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-660000
- 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-006231 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-16: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 7 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 Harbor Reference Lab (4121885428). | |
| 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: Harbor Reference Lab2026-01-16 09:04
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029829 | 2025-12-12 | Meadow Clinical Laboratories | $71.00 | Approved |
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.