CLM-2026-014768
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-06-25 at independent laboratory (POS 81). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- John Maldonado
- Member ID
- UHC-04570-68
- Date of birth
- 1943-04-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430606
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2167
- Coverage period
- 2022-05-01 to present
- Deductible
- $856.54 of $1,000.0086%
- Out-of-pocket maximum
- $374.57 of $2,000.0019%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 8920689386
- Network
- In network
- Rendering NPI
- 8920689386
- Location
- Mesa, AZ · TIN 50-3391688
- 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 | — | 1 | 1 | $32.00 | $19.84 | $19.84 | $0.00 | Paid |
| Totals | $32.00 | $19.84 | $19.84 | $0.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-495783
- 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-007949 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-25: SELECT-EPO (EPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 40 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 Clinical Laboratories (8920689386). | |
| 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 Clinical Laboratories2026-06-25 13:10
Established patient presents with hyperlipidemia, unspecified; 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 system2026-08-04 01:50
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-04 09:37
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-495783.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 engineApproved2026-10-21 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
Authorisation must be confirmed with UM before payment.