CLM-2026-014297
Unity Reference Lab, Clinical Laboratory. Service 2026-07-03 at independent laboratory (POS 81). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Martha Elliott
- Member ID
- none on golden record
- Date of birth
- 1939-10-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423352
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-3873
- Coverage period
- 2022-10-01 to present
- Deductible
- $334.95 of $1,000.0033%
- Out-of-pocket maximum
- $278.96 of $2,000.0014%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4863274690
- Network
- In network
- Rendering NPI
- 4863274690
- Location
- Houston, TX · TIN 64-5514010
- 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 | 85025 | Complete blood count with differential | 59 | 1 | 1 | $63.00 | $39.06 | — | — | PendedIDQ |
| 2 | 80061 | Lipid panel | 59 | 1 | 1 | $43.00 | $26.66 | — | — | PendedIDQ |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $67.00 | $41.54 | — | — | PendedIDQ |
| 4 | 83036 | Hemoglobin A1c | — | 1 | 2 | $59.00 | $36.58 | — | — | PendedIDQ |
| Totals | $232.00 | $143.84 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-694717
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001808; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-03: MEDICARE-ADV-B (MA), effective 2022-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 18 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 Unity Reference Lab (4863274690). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Unity Reference Lab2026-07-03 12:17
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-07-21 01:01
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-21 08:41
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-694717.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001808; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-03: MEDICARE-ADV-B (MA), effective 2022-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.