CLM-2026-011044
Lakeside Reference Lab, Clinical Laboratory. Service 2026-03-11 at independent laboratory (POS 81). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Samantha Jones
- Member ID
- UHC-43746-71
- Date of birth
- 1956-09-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420895
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3734
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,632.81 of $3,500.0047%
- Out-of-pocket maximum
- $1,154.32 of $14,000.008%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5657642919
- Network
- In network
- Rendering NPI
- 5657642919
- Location
- Charlotte, NC · TIN 76-9243358
- Authorisation / referral
- none / REF472474
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 | $72.00 | $44.64 | $44.64 | $0.00 | Paid |
| Totals | $72.00 | $44.64 | $44.64 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-553616
- 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-014265 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-11: NAVIGATE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 13 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 Lakeside Reference Lab (5657642919). | |
| 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: Lakeside Reference Lab2026-03-11 09:22
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 engineApproved2026-10-21 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
Clean claim, priced at contract rate.