CLM-2026-022854
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-05-23 at independent laboratory (POS 81). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Rebecca Kennedy
- Member ID
- UHC-19364-47
- Date of birth
- 1945-09-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-401054
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,469.00 of $2,500.0059%
- Out-of-pocket maximum
- $1,353.98 of $7,500.0018%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 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 | 80061 | Lipid panel | — | 1 | 1 | $72.00 | $44.64 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $47.00 | $29.14 | — | — | Review |
| 3 | 87086 | Urine culture | — | 1 | 1 | $47.00 | $29.14 | — | — | Review |
| Totals | $166.00 | $102.92 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-448506
- 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-027769 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: N/A (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 4 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: “Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vital”. 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 Laboratories2026-05-23 11:07
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-27 06:05
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-27 10:04
Escalated to nurse reviewer for clinical opinion.
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: “Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vital”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012360 | 2026-08-11 | Canyon Community Hospital | $3,338.00 | Approved |
| CLM-2026-028800 | 2026-06-27 | Mesa Orthopedic Specialists | $1,624.00 | Approved |
| CLM-2026-033869 | 2026-04-05 | Harbor Medical Group | $550.00 | 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.