Professional claim · CMS-1500 · EDI 837P
CLM-2026-018247
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-06-20 at independent laboratory (POS 81). Received 2026-07-23.
Approved
Billed
$236.00
4 lines
Allowed
$146.32
contract rate applied
Plan pays
$0.00
approved
Member owes
$146.32
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Gabriel Gray
- Member ID
- UHC-31656-92
- Date of birth
- 1962-05-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-413429
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3245
- Coverage period
- 2022-07-01 to present
- Deductible
- $2,025.58 of $3,500.0058%
- Out-of-pocket maximum
- $371.75 of $14,000.003%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- Authorisation / referral
- none / REF386256
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 | 87086 | Urine culture | — | 1 | 1 | $63.00 | $39.06 | $39.06 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $46.00 | $28.52 | $28.52 | $0.00 | Paid |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $60.00 | $37.20 | $37.20 | $0.00 | Paid |
| 4 | 83036 | Hemoglobin A1c | — | 1 | 2 | $67.00 | $41.54 | $41.54 | $0.00 | Paid |
| Totals | $236.00 | $146.32 | $146.32 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-312473
- 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-026037 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-20: CORE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 33 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 Sunrise Clinical Laboratories (1737179139). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Clinical Laboratories2026-06-20 18:09
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$236.00
Plan discount
$89.68
contracted rate
Plan paid
$0.00
You may owe
$146.32
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018248 | 2026-06-20 | Cornerstone Reference Lab | $236.00 | Needs review |
| CLM-2026-032253 | 2026-04-09 | Canyon Medical Group | $105.00 | Approved |
| CLM-2026-004524 | 2026-03-02 | Valley Internal Medicine Associates | $54.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.