CLM-2026-010482
Valley Reference Lab, Clinical Laboratory. Service 2026-07-22 at independent laboratory (POS 81). Received 2026-08-22.
Member
Resolved through the identity graph
- Member
- Julia Powell
- Member ID
- UHC-20456-59
- Date of birth
- 1982-02-15
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-408631
- Relationship
- Child
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6492
- Coverage period
- 2024-11-01 to present
- Deductible
- $311.43 of $500.0062%
- Out-of-pocket maximum
- $134.17 of $1,000.0013%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 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 / 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $50.00 | $31.00 | — | — | PendedIDQ |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $37.00 | $22.94 | — | — | PendedIDQ |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $36.00 | $22.32 | — | — | PendedIDQ |
| Totals | $123.00 | $76.26 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-893907
- 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 | Fail | IDQ | Member record is in open steward case CASE-001372; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-07-22: CHOICE-PLUS-PPO (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 31 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Reference Lab2026-07-22 15:20
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001372; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.