Professional claim · CMS-1500 · Provider portal
CLM-2026-009715
Mesa Clinical Laboratories, Clinical Laboratory. Service 2025-12-28 at independent laboratory (POS 81). Received 2026-02-07.
ApprovedOut of network
Billed
$193.00
4 lines
Allowed
$86.85
contract rate applied
Plan pays
$0.00
approved
Member owes
$86.85
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Priya Rogers
- Member ID
- UHC-59829-72
- Date of birth
- 1973-04-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413311
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0889
- Coverage period
- 2021-01-01 to present
- Deductible
- $108.55 of $1,000.0011%
- Out-of-pocket maximum
- $1,917.95 of $4,000.0048%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2023964945
- Network
- Out of network
- Rendering NPI
- 2023964945
- Location
- Atlanta, GA · TIN 12-9444799
- 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 | $40.00 | $18.00 | $18.00 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1,2 | $43.00 | $19.35 | $19.35 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $38.00 | $17.10 | $17.10 | $0.00 | Paid |
| 4 | 80061 | Lipid panel | — | 1 | 1 | $72.00 | $32.40 | $32.40 | $0.00 | Paid |
| Totals | $193.00 | $86.85 | $86.85 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-703638
- 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-011275 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-28: CHOICE-PLUS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 41 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Clinical Laboratories2025-12-28 09:10
Patient seen for urinary tract infection, site not specified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$193.00
Plan discount
$106.15
out-of-network allowance
Plan paid
$0.00
You may owe
$86.85
copay, deductible and coinsurance
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-2026-026645 | 2026-01-11 | Heritage Primary Care Associates | $569.00 | Approved |
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.