CLM-2026-007064
Valley Clinical Laboratories, Clinical Laboratory. Service 2026-04-09 at independent laboratory (POS 81). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- James Wright
- Member ID
- UHC-88515-11
- Date of birth
- 1993-08-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-420515
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0788
- Coverage period
- 2024-06-01 to present
- Deductible
- $956.92 of $1,500.0064%
- Out-of-pocket maximum
- $1,243.70 of $6,000.0021%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5408693625
- Network
- Out of network
- Rendering NPI
- 5408693625
- Location
- Tampa, FL · TIN 43-5217451
- 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 | $83.00 | $37.35 | $37.35 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1 | $55.00 | $24.75 | $24.75 | $0.00 | Paid |
| Totals | $138.00 | $62.10 | $62.10 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-459732
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025483 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-09: NULL (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 3 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Clinical Laboratories2026-04-09 16:48
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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027567 | 2026-09-14 | Pinecrest Cardiovascular Associates | $8,092.00 | 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.