CLM-2026-009960
Unity Reference Lab, Clinical Laboratory. Service 2026-01-20 at independent laboratory (POS 81). Received 2026-02-05.
Member
Resolved through the identity graph
- Member
- Heather Webb
- Member ID
- UHC-98163-77
- Date of birth
- 1971-06-17
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-411251
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4791
- Coverage period
- 2023-06-01 to present
- Deductible
- $255.88 of $500.0051%
- Out-of-pocket maximum
- $414.21 of $1,000.0041%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4863274690
- Network
- In network
- Rendering NPI
- 4863274690
- Location
- Houston, TX · TIN 64-5514010
- 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 | 87086 | Urine culture | — | 1 | 1 | $36.00 | $22.32 | $22.32 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $88.00 | $54.56 | $54.56 | $0.00 | Paid |
| Totals | $124.00 | $76.88 | $76.88 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-332930
- 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-010511 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-20: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| 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 Unity Reference Lab (4863274690). | |
| 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: Unity Reference Lab2026-01-20 14:52
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-02-05 02:59
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-05 10:53
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-332930.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
Authorisation must be confirmed with UM before payment.