CLM-2026-017650
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-03-09 at independent laboratory (POS 81). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Lisa Anderson
- Member ID
- UHC-07284-72
- Date of birth
- 1951-12-09
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-423241
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7803
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,286.27 of $3,500.0037%
- Out-of-pocket maximum
- $1,106.61 of $10,500.0011%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4658545775
- Network
- In network
- Rendering NPI
- 4658545775
- Location
- Nashville, TN · TIN 46-3944413
- 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 | $53.00 | $32.86 | $32.86 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | 25 | 1 | 1 | $56.00 | $34.72 | $34.72 | $0.00 | Paid |
| Totals | $109.00 | $67.58 | $67.58 | $0.00 | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-211777
- 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-023161 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-09: MEDICARE-ADV-A (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 22 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 (4658545775). | |
| 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 Laboratories2026-03-09 18:43
Established patient presents with urinary tract infection, site not specified; 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 system2026-03-31 05:06
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-211777.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 engineApproved2026-10-22 12:44Clean 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.