CLM-2026-010099
Summit Reference Lab, Clinical Laboratory. Service 2025-12-23 at independent laboratory (POS 81). Received 2026-01-30.
Member
Resolved through the identity graph
- Member
- Jack Lee
- Member ID
- UHC-43520-33
- Date of birth
- 1991-08-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402388
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4649
- Coverage period
- 2021-08-01 to present
- Deductible
- $246.42 of $2,500.0010%
- Out-of-pocket maximum
- $745.76 of $5,000.0015%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7256801888
- Network
- Out of network
- Rendering NPI
- 7256801888
- Location
- Scottsdale, AZ · TIN 41-8218808
- 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 | $68.00 | $30.60 | $30.60 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $48.00 | $21.60 | $21.60 | $0.00 | Paid |
| Totals | $116.00 | $52.20 | $52.20 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-596551
- 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-004243 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-23: MEDICARE-ADV-B (MA), effective 2021-08-01. | |
| Timely filing | Pass | Received 38 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Reference Lab2025-12-23 18:45
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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.