CLM-2026-018488
Unity Reference Lab, Clinical Laboratory. Service 2025-12-19 at independent laboratory (POS 81). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Valentina Ortiz
- Member ID
- UHC-17863-08
- Date of birth
- 1953-05-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411991
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3889
- Coverage period
- 2021-04-01 to present
- Deductible
- $654.59 of $1,000.0065%
- Out-of-pocket maximum
- $768.50 of $3,000.0026%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4863274690
- Network
- In network
- Rendering NPI
- 4863274690
- Location
- Houston, TX · TIN 64-5514010
- 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 | $60.00 | $37.20 | $37.20 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $63.00 | $39.06 | $39.06 | $0.00 | Paid |
| 3 | 87086 | Urine culture | — | 1 | 1 | $34.00 | $21.08 | $21.08 | $0.00 | Paid |
| Totals | $157.00 | $97.34 | $97.34 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-382339
- 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-003130 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-19: MEDICARE-ADV-A (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 22 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 Reference Lab (4863274690). | |
| 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 Reference Lab2025-12-19 13:58
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012651 | 2026-05-24 | Lakeside Internal Medicine Associates | $72.00 | 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
Clean claim, priced at contract rate.