Professional claim · CMS-1500 · Paper
CLM-2026-009190
Unity Reference Lab, Clinical Laboratory. Service 2026-04-17 at independent laboratory (POS 81). Received 2026-04-26.
Approved
Billed
$252.00
4 lines
Allowed
$156.24
contract rate applied
Plan pays
$0.00
approved
Member owes
$156.24
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Diego West
- Member ID
- UHC-45695-22
- Date of birth
- 1962-07-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403071
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5435
- Coverage period
- 2024-12-01 to present
- Deductible
- $113.45 of $2,500.005%
- Out-of-pocket maximum
- $266.46 of $5,000.005%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4372283836
- Network
- In network
- Rendering NPI
- 4372283836
- Location
- Phoenix, AZ · TIN 58-9749325
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $63.00 | $39.06 | $39.06 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $51.00 | $31.62 | $31.62 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $68.00 | $42.16 | $42.16 | $0.00 | Paid |
| 4 | 87086 | Urine culture | — | 1 | 1 | $70.00 | $43.40 | $43.40 | $0.00 | Paid |
| Totals | $252.00 | $156.24 | $156.24 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-948285
- 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-000138 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-17: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 9 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 Unity Reference Lab (4372283836). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Reference Lab2026-04-17 15:49
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$252.00
Plan discount
$95.76
contracted rate
Plan paid
$0.00
You may owe
$156.24
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031517 | 2026-05-25 | Sunrise Clinical Laboratories | $31.00 | Approved |
| CLM-2026-001528 | 2026-03-21 | Sunrise Clinical Laboratories | $115.00 | Needs review |
| CLM-2026-001527 | 2026-03-21 | Desert Reference Lab | $115.00 | Approved |
| CLM-2026-028216 | 2025-12-02 | Heritage Medical Group | $54.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.