CLM-2026-008558
Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-02-06 at independent laboratory (POS 81). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Anna Payne
- Member ID
- UHC-93456-64
- Date of birth
- 1966-11-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426207
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5398
- Coverage period
- 2022-06-01 to present
- Deductible
- $418.70 of $1,000.0042%
- Out-of-pocket maximum
- $179.25 of $2,000.009%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4514050481
- Network
- In network
- Rendering NPI
- 4514050481
- Location
- Tempe, AZ · TIN 12-2226671
- Authorisation / referral
- none / REF794265
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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $79.00 | $48.98 | $48.98 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1,2 | $65.00 | $40.30 | $40.30 | $0.00 | Paid |
| 3 | 87086 | Urine culture | — | 1 | 1,2 | $37.00 | $22.94 | $22.94 | $0.00 | Paid |
| Totals | $181.00 | $112.22 | $112.22 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-130671
- 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-013875 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-06: NAVIGATE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 11 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 Riverside Clinical Laboratories (4514050481). | |
| 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: Riverside Clinical Laboratories2026-02-06 16:57
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 engineApproved2026-10-21 13:43Clean 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.