CLM-2026-009378
Summit Clinical Laboratories, Clinical Laboratory. Service 2026-06-24 at independent laboratory (POS 81). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Henry Ross
- Member ID
- UHC-22131-74
- Date of birth
- 1987-12-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-424047
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2023-04-01 to present
- Deductible
- $477.68 of $2,500.0019%
- Out-of-pocket maximum
- $1,534.34 of $7,500.0020%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 3912329836
- Network
- In network
- Rendering NPI
- 3912329836
- Location
- Nashville, TN · TIN 38-7470413
- 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 | $50.00 | $31.00 | $31.00 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1 | $63.00 | $39.06 | $39.06 | $0.00 | Paid |
| Totals | $113.00 | $70.06 | $70.06 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-194018
- 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-037949 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-24: N/A (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 16 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 Summit Clinical Laboratories (3912329836). | |
| 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: Summit Clinical Laboratories2026-06-24 11:25
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-2026-032696 | 2026-09-12 | Lakeside Medical Group | $363.00 | Approved |
| CLM-2026-025353 | 2026-07-02 | Mesa Cardiovascular Associates | $291.00 | 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.