CLM-2026-021938
Heritage Clinical Laboratories, Clinical Laboratory. Service 2025-12-24 at independent laboratory (POS 81). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Bakeer Daneille
- Member ID
- UHC-85743-44
- Date of birth
- 1945-05-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431097
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7764
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,636.70 of $2,500.0065%
- Out-of-pocket maximum
- $565.09 of $5,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6061087964
- Network
- In network
- Rendering NPI
- 6061087964
- Location
- Scottsdale, AZ · TIN 58-0891898
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $65.00 | $40.30 | $40.30 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $84.00 | $52.08 | $52.08 | $0.00 | Paid |
| Totals | $149.00 | $92.38 | $92.38 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-995039
- 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-006510 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-24: SELECT-EPO (EPO), effective 2021-09-01. | |
| 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 Heritage Clinical Laboratories (6061087964). | |
| 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: Heritage Clinical Laboratories2025-12-24 12:14
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
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.