CLM-2026-014801
Pinecrest Clinical Laboratories, Clinical Laboratory. Service 2026-04-28 at independent laboratory (POS 81). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Roger Ortiz
- Member ID
- UHC-26091-54
- Date of birth
- 1970-12-19
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-400200
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group N/A
- Coverage period
- 2025-06-01 to 2026-04-28
- Deductible
- $334.13 of $500.0067%
- Out-of-pocket maximum
- $293.29 of $2,000.0015%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6068288409
- Network
- In network
- Rendering NPI
- 6068288409
- Location
- San Diego, CA · TIN 41-0079440
- 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 | $67.00 | $41.54 | $41.54 | $0.00 | Paid |
| Totals | $67.00 | $41.54 | $41.54 | $0.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-213785
- 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-021103 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-28: NULL (PPO), effective 2025-06-01, terms 2026-04-28. | |
| Timely filing | Pass | Received 37 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 Pinecrest Clinical Laboratories (6068288409). | |
| 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: Pinecrest Clinical Laboratories2026-04-28 17:07
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-04 05:08
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-04 14:17
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
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-2026-015632 | 2026-04-21 | Desert Diagnostic Imaging | $491.00 | 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
Service after coverage termination.