CLM-2026-016735
Desert Reference Lab, Clinical Laboratory. Service 2026-05-24 at independent laboratory (POS 81). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Albert Marshall
- Member ID
- UHC-01330-32
- Date of birth
- 1991-07-04
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-413940
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2688
- Coverage period
- 2022-01-01 to present
- Deductible
- $44.69 of $1,000.004%
- Out-of-pocket maximum
- $520.81 of $2,000.0026%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8770600343
- Network
- In network
- Rendering NPI
- 8770600343
- Location
- Charlotte, NC · TIN 95-8427409
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $75.00 | $46.50 | $46.50 | $0.00 | Paid |
| Totals | $75.00 | $46.50 | $46.50 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-803342
- 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-023427 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-24: OPTIONS-PPO (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 5 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 Desert Reference Lab (8770600343). | |
| 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: Desert Reference Lab2026-05-24 15:16
Patient seen for essential (primary) hypertension. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-29 02:36
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-29 11:01
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-803342.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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024530 | 2026-06-23 | Evergreen Rehabilitation Center | $164.00 | Approved |
| CLM-2026-015741 | 2026-06-10 | Pinecrest Physical Therapy | $187.00 | Approved |
| CLM-2026-013156 | 2026-02-27 | Lakeside Imaging Center | $599.00 | 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
Authorisation must be confirmed with UM before payment.