CLM-2026-016081
Unity Clinical Laboratories, Clinical Laboratory. Service 2025-10-12 at independent laboratory (POS 81). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Alexander Hudson
- Member ID
- none on golden record
- Date of birth
- 1964-03-17
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427162
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-3331
- Coverage period
- 2022-09-01 to present
- Deductible
- $199.60 of $1,000.0020%
- Out-of-pocket maximum
- $607.56 of $3,000.0020%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1092116486
- Network
- In network
- Rendering NPI
- 1092116486
- Location
- Houston, TX · TIN 34-8016251
- 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 | 80061 | Lipid panel | — | 1 | 1 | $77.00 | $47.74 | — | — | DeniedCO29 |
| Totals | $77.00 | $47.74 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-678206
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
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-002202; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-10-12: MEDICARE-ADV-A (MA), effective 2022-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Fail | CO29 | Received 214 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Clinical Laboratories (1092116486). | |
| 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: Unity Clinical Laboratories2025-10-12 18:13
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-14 03:41
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-002202; payment withheld until the identity is confirmed. Eligibility: Active on 2025-10-12: MEDICARE-ADV-A (MA), effective 2022-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 214 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.