CLM-2026-011154
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-07-13 at independent laboratory (POS 81). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Martha Patterson
- Member ID
- UHC-85609-56
- Date of birth
- 1991-05-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424291
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0653
- Coverage period
- 2024-07-01 to present
- Deductible
- $271.99 of $1,500.0018%
- Out-of-pocket maximum
- $1,150.53 of $3,000.0038%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- 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 | $42.00 | $26.04 | $26.04 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $48.00 | $29.76 | $29.76 | $0.00 | Paid |
| Totals | $90.00 | $55.80 | $55.80 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-275629
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008536 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-13: OPTIONS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 6 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 Sunrise Clinical Laboratories (1737179139). | |
| 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: Sunrise Clinical Laboratories2026-07-13 11:11
Established patient presents with type 2 diabetes mellitus without complications; 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 system2026-07-19 00:48
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-275629.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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006659 | 2026-02-23 | Canyon Counseling Center | $223.00 | Approved |
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.