CLM-2026-010581
Meadow Clinical Laboratories, Clinical Laboratory. Service 2026-06-05 at independent laboratory (POS 81). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Sophia Wilson
- Member ID
- UHC-22018-02
- Date of birth
- 1958-10-14
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-405112
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7528
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,486.06 of $2,500.0059%
- Out-of-pocket maximum
- $3,695.96 of $10,000.0037%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6855554898
- Network
- In network
- Rendering NPI
- 6855554898
- Location
- Scottsdale, AZ · TIN 20-9059141
- Authorisation / referral
- none / REF307919
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 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| Totals | $61.00 | $37.82 | $37.82 | $0.00 | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-221113
- 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-033157 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-05: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 7 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 Meadow Clinical Laboratories (6855554898). | |
| 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: Meadow Clinical Laboratories2026-06-05 14:18
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-12 06:35
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-221113.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.