Professional claim · CMS-1500 · EDI 837P
CLM-2026-012621
Desert Clinical Laboratories, Clinical Laboratory. Service 2026-04-14 at independent laboratory (POS 81). Received 2026-05-14.
Approved
Billed
$173.00
3 lines
Allowed
$107.26
contract rate applied
Plan pays
$0.00
approved
Member owes
$107.26
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Shirley Soto
- Member ID
- UHC-96595-31
- Date of birth
- 1948-09-15
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-426385
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6810
- Coverage period
- 2025-08-01 to present
- Deductible
- $641.37 of $3,500.0018%
- Out-of-pocket maximum
- $1,516.96 of $10,500.0014%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9068366761
- Network
- In network
- Rendering NPI
- 9068366761
- Location
- Houston, TX · TIN 28-8573609
- 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 | $54.00 | $33.48 | $33.48 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1,2 | $67.00 | $41.54 | $41.54 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $52.00 | $32.24 | $32.24 | $0.00 | Paid |
| Totals | $173.00 | $107.26 | $107.26 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-492458
- 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-000721 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-14: MEDICARE-ADV-B (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 30 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 Desert Clinical Laboratories (9068366761). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Clinical Laboratories2026-04-14 15:24
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$173.00
Plan discount
$65.74
contracted rate
Plan paid
$0.00
You may owe
$107.26
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021249 | 2026-07-08 | Unity Dermatology Clinic | $312.00 | Approved |
| CLM-2026-020308 | 2026-07-26 | Riverside Primary Care Associates | $546.00 | Approved |
| CLM-2026-020038 | 2026-07-25 | Evergreen Counseling Center | $238.00 | Needs review |
| CLM-2026-020037 | 2026-07-25 | Evergreen Counseling Center | $238.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.