Professional claim · CMS-1500 · Provider portal
CLM-2026-020400
Meadow Reference Lab, Clinical Laboratory. Service 2026-01-22 at independent laboratory (POS 81). Received 2026-02-07.
ApprovedOut of network
Billed
$86.00
2 lines
Allowed
$38.70
contract rate applied
Plan pays
$0.00
approved
Member owes
$38.70
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ronald Cox
- Member ID
- UHC-07390-48
- Date of birth
- 1994-08-04
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-432400
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4509
- Coverage period
- 2023-10-01 to present
- Deductible
- $2,206.10 of $3,500.0063%
- Out-of-pocket maximum
- $3,335.86 of $7,000.0048%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 3840164321
- Network
- Out of network
- Rendering NPI
- 3840164321
- Location
- Los Angeles, CA · TIN 14-8564922
- 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 | $38.00 | $17.10 | $17.10 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $48.00 | $21.60 | $21.60 | $0.00 | Paid |
| Totals | $86.00 | $38.70 | $38.70 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-611173
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000249 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-22: OPTIONS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 16 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Reference Lab2026-01-22 12:53
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$86.00
Plan discount
$47.30
out-of-network allowance
Plan paid
$0.00
You may owe
$38.70
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014369 | 2026-03-13 | Riverside Diagnostic Imaging | $1,260.00 | 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.