CLM-2026-016979
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-04-15 at independent laboratory (POS 81). Received 2026-04-30.
Member
Resolved through the identity graph
- Member
- Roy Bennett
- Member ID
- UHC-17845-80
- Date of birth
- 1950-11-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404790
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4177
- Coverage period
- 2021-02-01 to present
- Deductible
- $2,586.40 of $3,500.0074%
- Out-of-pocket maximum
- $4,641.85 of $10,500.0044%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7837946178
- Network
- In network
- Rendering NPI
- 7837946178
- Location
- Miami, FL · TIN 25-9657303
- 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 | $60.00 | $37.20 | $37.20 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $56.00 | $34.72 | $34.72 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $40.00 | $24.80 | $24.80 | $0.00 | Paid |
| Totals | $156.00 | $96.72 | $96.72 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-538844
- 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-028381 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: SELECT-EPO (EPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 15 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 Mesa Clinical Laboratories (7837946178). | |
| 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: Mesa Clinical Laboratories2026-04-15 18:11
Patient seen for type 2 diabetes mellitus without complications.
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027280 | 2026-06-11 | Unity Cardiovascular Associates | $490.00 | 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
Clean claim, priced at contract rate.