Professional claim · CMS-1500 · EDI 837P
CLM-2026-022093
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-04-01 at independent laboratory (POS 81). Received 2026-04-18.
ApprovedOut of network
Billed
$221.00
4 lines
Allowed
$99.45
contract rate applied
Plan pays
$0.00
approved
Member owes
$99.45
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ralph Andrews
- Member ID
- UHC-03242-36
- Date of birth
- 1985-06-10
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-431959
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4598
- Coverage period
- 2025-09-01 to present
- Deductible
- $834.94 of $1,000.0083%
- Out-of-pocket maximum
- $1,037.25 of $4,000.0026%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5966486339
- Network
- Out of network
- Rendering NPI
- 5966486339
- Location
- San Diego, CA · TIN 79-8835639
- 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 | $55.00 | $24.75 | $24.75 | $0.00 | Paid |
| 2 | 87086 | Urine culture | 25 | 1 | 1 | $45.00 | $20.25 | $20.25 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $46.00 | $20.70 | $20.70 | $0.00 | Paid |
| 4 | 80061 | Lipid panel | — | 1 | 2 | $75.00 | $33.75 | $33.75 | $0.00 | Paid |
| Totals | $221.00 | $99.45 | $99.45 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-482967
- 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-007960 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-01: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 17 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Cornerstone Reference Lab2026-04-01 18:20
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$221.00
Plan discount
$121.55
out-of-network allowance
Plan paid
$0.00
You may owe
$99.45
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019738 | 2026-07-05 | Sunrise Internal Medicine Associates | $330.00 | Approved |
| CLM-2026-031655 | 2026-01-24 | Desert Reference Lab | $49.00 | Approved |
| CLM-2026-005128 | 2025-12-13 | Mesa Primary Care Associates | $216.00 | 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.