CLM-2026-020977
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-02-08 at independent laboratory (POS 81). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Christian Peterson
- Member ID
- UHC-46520-71
- Date of birth
- 1969-06-14
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-422492
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-4386
- Coverage period
- 2021-10-01 to present
- Deductible
- $1,205.40 of $1,500.0080%
- Out-of-pocket maximum
- $1,855.90 of $4,500.0041%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4740334576
- Network
- In network
- Rendering NPI
- 4740334576
- Location
- Mesa, AZ · TIN 57-0560500
- 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 | $76.00 | $47.12 | $47.12 | $0.00 | Paid |
| Totals | $76.00 | $47.12 | $47.12 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-539609
- 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-000204 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-08: UNKNOWN (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 38 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 Cornerstone Reference Lab (4740334576). | |
| 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: Cornerstone Reference Lab2026-02-08 10:41
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000666 | 2026-04-21 | Pinecrest Bone and Joint Center | $405.00 | 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.