CLM-2026-021136
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-03-07 at independent laboratory (POS 81). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Jose Mejia
- Member ID
- UHC-36493-03
- Date of birth
- 1978-12-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420118
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1847
- Coverage period
- 2023-05-01 to present
- Deductible
- $391.48 of $500.0078%
- Out-of-pocket maximum
- $296.48 of $1,000.0030%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- 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 | $79.00 | $48.98 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $88.00 | $54.56 | — | — | Review |
| Totals | $167.00 | $103.54 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-559495
- 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-001214 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-07: MEDICARE-ADV-A (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 21 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 Sunrise Clinical Laboratories (1737179139). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Clinical Laboratories2026-03-07 13:17
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-28 01:16
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-28 11:27
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005024 | 2026-05-13 | Desert Internal Medicine Associates | $65.00 | Approved |
| CLM-2026-021384 | 2025-12-01 | Mesa Orthopedic Specialists | $34,233.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.