CLM-2026-018055
Harbor Reference Lab, Clinical Laboratory. Service 2026-08-24 at independent laboratory (POS 81). Received 2026-09-20.
Member
Resolved through the identity graph
- Member
- Sean Howell
- Member ID
- UHC-66065-50
- Date of birth
- 1979-03-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-426930
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1018
- Coverage period
- 2024-01-01 to present
- Deductible
- $835.22 of $3,500.0024%
- Out-of-pocket maximum
- $1,063.24 of $14,000.008%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4121885428
- Network
- In network
- Rendering NPI
- 4121885428
- Location
- Tempe, AZ · TIN 21-1131562
- 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 | $80.00 | $49.60 | $49.60 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1 | $56.00 | $34.72 | $34.72 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $44.00 | $27.28 | $27.28 | $0.00 | Paid |
| 4 | 80061 | Lipid panel | — | 1 | 2 | $83.00 | $51.46 | $51.46 | $0.00 | Paid |
| Totals | $263.00 | $163.06 | $163.06 | $0.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-705380
- 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-029859 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-24: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 27 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 Harbor Reference Lab (4121885428). | |
| 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: Harbor Reference Lab2026-08-24 10:59
Patient seen for hyperlipidemia, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-20 06:56
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-705380.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-2026-019852 | 2026-05-23 | Sunrise Diabetes Center | $444.00 | Approved |
| CLM-2026-002308 | 2026-05-04 | Harbor Family Practice | $384.00 | 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.