CLM-2026-021707
Unity Clinical Laboratories, Clinical Laboratory. Service 2025-12-03 at independent laboratory (POS 81). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Christopher Willis
- Member ID
- UHC-00681-59
- Date of birth
- 1971-11-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413575
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5686
- Coverage period
- 2021-12-01 to present
- Deductible
- $184.65 of $3,500.005%
- Out-of-pocket maximum
- $829.28 of $7,000.0012%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1092116486
- Network
- In network
- Rendering NPI
- 1092116486
- Location
- Houston, TX · TIN 34-8016251
- 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 | $43.00 | $26.66 | — | — | Review |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $55.00 | $34.10 | — | — | Review |
| Totals | $98.00 | $60.76 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-213372
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004038 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-03: MEDICARE-ADV-B (MA), effective 2021-12-01. | |
| Timely filing | Pass | Received 41 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 Unity Clinical Laboratories (1092116486). | |
| 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 hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”. 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: Unity Clinical Laboratories2025-12-03 10:49
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-13 05:36
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-13 17:07
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:43 · a306b3f1
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019760 | 2026-01-05 | Sunrise Digestive Health Center | $280.00 | Approved |
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.