Professional claim · CMS-1500 · EDI 837P
CLM-2026-013302
Evergreen Reference Lab, Clinical Laboratory. Service 2026-09-23 at independent laboratory (POS 81). Received 2026-09-29.
Approved
Billed
$193.00
3 lines
Allowed
$119.66
contract rate applied
Plan pays
$0.00
approved
Member owes
$119.66
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
- Aisha Simmons
- Member ID
- UHC-46654-44
- Date of birth
- 1944-04-21
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-402338
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9597
- Coverage period
- 2021-11-01 to present
- Deductible
- $221.18 of $500.0044%
- Out-of-pocket maximum
- $713.28 of $2,000.0036%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- Authorisation / referral
- none / REF686219
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 | $69.00 | $42.78 | $42.78 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $43.00 | $26.66 | $26.66 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $81.00 | $50.22 | $50.22 | $0.00 | Paid |
| Totals | $193.00 | $119.66 | $119.66 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-490109
- 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-006954 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-23: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| 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 Evergreen Reference Lab (6979403576). | |
| 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: Evergreen Reference Lab2026-09-23 10:28
Patient seen for urinary tract infection, site not specified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$193.00
Plan discount
$73.34
contracted rate
Plan paid
$0.00
You may owe
$119.66
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-2026-033848 | 2026-07-06 | Meadow Physical Therapy | $152.00 | Denied |
| CLM-2026-002277 | 2026-07-29 | Riverside Community Hospital | $1,723.00 | Approved |
| CLM-2026-019749 | 2026-04-22 | Lakeside Bone and Joint Center | $195.00 | Approved |
| CLM-2026-010764 | 2026-03-10 | Canyon Cardiovascular Associates | $1,923.00 | 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.