CLM-2026-018672
Evergreen Reference Lab, Clinical Laboratory. Service 2025-12-26 at independent laboratory (POS 81). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Sandra Hart
- Member ID
- UHC-88610-44
- Date of birth
- 1957-12-16
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-429797
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6806
- Coverage period
- 2022-03-01 to present
- Deductible
- $171.40 of $1,000.0017%
- Out-of-pocket maximum
- $1,636.78 of $4,000.0041%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 17 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $75.00 | $46.50 | $46.50 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $75.00 | $46.50 | $46.50 | $0.00 | Paid |
| 3 | 87086 | Urine culture | — | 1 | 2 | $65.00 | $40.30 | $40.30 | $0.00 | Paid |
| Totals | $215.00 | $133.30 | $133.30 | $0.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-674519
- 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-004045 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-26: SELECT-EPO (EPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 18 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 Lab2025-12-26 17:11
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
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-2026-006276 | 2026-07-28 | Riverside Primary Care Associates | $441.00 | Approved |
| CLM-2026-008456 | 2026-07-18 | Unity Family Practice | $244.00 | 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.