CLM-2026-008107
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2025-09-11 at independent laboratory (POS 81). Received 2026-02-23.
Member
Resolved through the identity graph
- Member
- Jacob Little
- Member ID
- UHC-14867-13
- Date of birth
- 1974-07-12
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-416878
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9106
- Coverage period
- 2025-04-01 to present
- Deductible
- $341.67 of $500.0068%
- Out-of-pocket maximum
- $316.21 of $1,500.0021%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- 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 | $45.00 | $27.90 | — | — | DeniedCO29 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $46.00 | $28.52 | — | — | DeniedCO29 |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $66.00 | $40.92 | — | — | DeniedCO29 |
| Totals | $157.00 | $97.34 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-378917
- 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-008440 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-11: OPTIONS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Fail | CO29 | Received 165 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Clinical Laboratories (1737179139). | |
| 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 Laboratories2025-09-11 17:50
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-23 01:41
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 165 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008793 | 2026-03-30 | Lakeside Medical Group | $231.00 | 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
Received after the timely-filing limit.