CLM-2026-019001
Lakeside Reference Lab, Clinical Laboratory. Service 2026-06-25 at independent laboratory (POS 81). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Wayne Santiago
- Member ID
- UHC-95759-83
- Date of birth
- 1999-03-04
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401584
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7293
- Coverage period
- 2024-06-01 to present
- Deductible
- $270.61 of $1,000.0027%
- Out-of-pocket maximum
- $834.39 of $4,000.0021%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8593662793
- Network
- In network
- Rendering NPI
- 8593662793
- Location
- Austin, TX · TIN 19-8347023
- 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 | $72.00 | $44.64 | $44.64 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | 25 | 1 | 2 | $47.00 | $29.14 | $29.14 | $0.00 | Paid |
| Totals | $119.00 | $73.78 | $73.78 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-186446
- 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-036942 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-25: SELECT-EPO (EPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 6 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 Lakeside Reference Lab (8593662793). | |
| 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: Lakeside Reference Lab2026-06-25 15:26
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-2026-012329 | 2026-09-20 | Heritage Family Practice | $2,586.00 | Needs review |
| CLM-2026-010599 | 2026-06-20 | Harbor Diagnostic Imaging | $2,729.00 | 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.