CLM-2026-017915
Unity Clinical Laboratories, Clinical Laboratory. Service 2026-08-19 at independent laboratory (POS 81). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Elijah West
- Member ID
- UHC-13763-06
- Date of birth
- 1967-12-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-406401
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group N/A
- Coverage period
- 2022-11-01 to present
- Deductible
- $94.26 of $500.0019%
- Out-of-pocket maximum
- $280.99 of $1,500.0019%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 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 / REF349313
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 | $64.00 | $39.68 | $39.68 | $0.00 | Paid |
| Totals | $64.00 | $39.68 | $39.68 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-751054
- 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-042994 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-19: CORE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 11 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 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 Laboratories2026-08-19 15:37
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 engineApproved2026-10-22 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
Clean claim, priced at contract rate.