Professional claim · CMS-1500 · Provider portal
CLM-2026-021856
Valley Reference Lab, Clinical Laboratory. Service 2026-08-06 at independent laboratory (POS 81). Received 2026-09-03.
Approved
Billed
$160.00
3 lines
Allowed
$99.20
contract rate applied
Plan pays
$0.00
approved
Member owes
$99.20
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Kenneth Martinez
- Member ID
- UHC-66774-91
- Date of birth
- 1966-11-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403248
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5749
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,930.74 of $2,500.0077%
- Out-of-pocket maximum
- $1,567.17 of $5,000.0031%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8777376848
- Network
- In network
- Rendering NPI
- 8777376848
- Location
- Minneapolis, MN · TIN 45-5717570
- Authorisation / referral
- none / REF136543
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 | 87086 | Urine culture | — | 1 | 1 | $47.00 | $29.14 | $29.14 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 2 | $52.00 | $32.24 | $32.24 | $0.00 | Paid |
| Totals | $160.00 | $99.20 | $99.20 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-734527
- 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-016078 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-06: NAVIGATE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 28 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 Valley Reference Lab (8777376848). | |
| 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: Valley Reference Lab2026-08-06 13:19
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$160.00
Plan discount
$60.80
contracted rate
Plan paid
$0.00
You may owe
$99.20
copay, deductible and coinsurance
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-2026-015598 | 2026-08-26 | Northgate Cardiovascular Associates | $310.00 | Approved |
| CLM-2026-028284 | 2026-06-04 | Meadow Medical Group | $2,532.00 | Needs review |
| CLM-2026-015700 | 2026-04-07 | Summit Medical Group | $393.00 | Approved |
| CLM-2026-004820 | 2026-05-01 | Valley Family Practice | $268.00 | 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.