CLM-2026-018230
Evergreen Reference Lab, Clinical Laboratory. Service 2026-04-19 at independent laboratory (POS 81). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Alice Henry
- Member ID
- UHC-71248-55
- Date of birth
- 1942-11-22
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-412433
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9613
- Coverage period
- 2022-09-01 to present
- Deductible
- $2,114.56 of $3,500.0060%
- Out-of-pocket maximum
- $2,779.18 of $10,500.0026%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 6979403576
- Network
- In network
- Rendering NPI
- 6979403576
- Location
- Miami, FL · TIN 38-5459375
- 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 | $69.00 | $42.78 | $42.78 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $68.00 | $42.16 | $42.16 | $0.00 | Paid |
| Totals | $137.00 | $84.94 | $84.94 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-248071
- 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-030383 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-04-19: OPTIONS-PPO (PPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 23 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 Evergreen Reference Lab (6979403576). | |
| 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: Evergreen Reference Lab2026-04-19 09:29
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
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.