CLM-2026-017716
Unity Clinical Laboratories, Clinical Laboratory. Service 2026-09-24 at independent laboratory (POS 81). Received 2026-10-22.
Member
Resolved through the identity graph
- Member
- Amber Delgado
- Member ID
- UHC-52060-85
- Date of birth
- 1998-09-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406933
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4860
- Coverage period
- 2025-07-01 to present
- Deductible
- $1,744.49 of $2,500.0070%
- Out-of-pocket maximum
- $1,908.31 of $7,500.0025%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $86.00 | $53.32 | — | — | DeniedCO18 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $61.00 | $37.82 | — | — | DeniedCO18 |
| Totals | $147.00 | $91.14 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-152152
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038706 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-24: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-017715: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Laboratories2026-09-24 13:01
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-22 00:31
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-017715: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017715 | 2026-09-24 | Unity Clinical Laboratories | $147.00 | Approved |
| CLM-2026-028504 | 2026-07-01 | Northgate Imaging Center | $3,494.00 | Approved |
| CLM-2026-023439 | 2026-07-04 | Mesa Family Practice | $262.00 | Approved |
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
Exact duplicate of an earlier submission.