Professional claim · CMS-1500 · EDI 837P
CLM-2026-009944
Valley Reference Lab, Clinical Laboratory. Service 2026-08-17 at independent laboratory (POS 81). Received 2026-09-15.
Approved
Billed
$155.00
3 lines
Allowed
$96.10
contract rate applied
Plan pays
$0.00
approved
Member owes
$96.10
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Joshua Sanders
- Member ID
- UHC-21780-50
- Date of birth
- 1952-06-07
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-412004
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2021-09-01 to present
- Deductible
- $383.56 of $500.0077%
- Out-of-pocket maximum
- $55.74 of $1,500.004%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8777376848
- Network
- In network
- Rendering NPI
- 8777376848
- Location
- Minneapolis, MN · TIN 45-5717570
- Authorisation / referral
- none / REF792094
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 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1 | $44.00 | $27.28 | $27.28 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $50.00 | $31.00 | $31.00 | $0.00 | Paid |
| Totals | $155.00 | $96.10 | $96.10 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-612135
- 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-005258 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-17: CORE-HMO (HMO), effective 2021-09-01. | |
| Timely filing | Pass | Received 29 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 Valley Reference Lab (8777376848). | |
| 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: Valley Reference Lab2026-08-17 15:40
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$155.00
Plan discount
$58.90
contracted rate
Plan paid
$0.00
You may owe
$96.10
copay, deductible and coinsurance
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-2026-021186 | 2026-05-23 | Summit Primary Care Associates | $215.00 | Approved |
| CLM-2026-024233 | 2026-04-04 | Valley Family Practice | $538.00 | Approved |
| CLM-2026-015262 | 2025-12-21 | Lakeside Clinical Laboratories | $88.00 | 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.