Professional claim · CMS-1500 · EDI 837P
CLM-2026-023211
Harbor Clinical Laboratories, Clinical Laboratory. Service 2026-06-22 at independent laboratory (POS 81). Received 2026-07-23.
ApprovedOut of network
Billed
$182.00
3 lines
Allowed
$81.90
contract rate applied
Plan pays
$0.00
approved
Member owes
$81.90
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
- Patrick Valdez
- Member ID
- UHC-71408-63
- Date of birth
- 1950-04-27
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-420464
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8637
- Coverage period
- 2025-02-01 to present
- Deductible
- $233.18 of $500.0047%
- Out-of-pocket maximum
- $868.77 of $2,000.0043%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2122435433
- Network
- Out of network
- Rendering NPI
- 2122435433
- Location
- Los Angeles, CA · TIN 12-4722693
- 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 | 87086 | Urine culture | — | 1 | 1 | $58.00 | $26.10 | $26.10 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $42.00 | $18.90 | $18.90 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $82.00 | $36.90 | $36.90 | $0.00 | Paid |
| Totals | $182.00 | $81.90 | $81.90 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-405368
- 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-000400 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-22: NULL (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 31 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: Harbor Clinical Laboratories2026-06-22 13:55
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$182.00
Plan discount
$100.10
out-of-network allowance
Plan paid
$0.00
You may owe
$81.90
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-2026-019473 | 2026-01-24 | Mesa Family Practice | $50.00 | Approved |
| CLM-2026-002692 | 2025-12-17 | Desert Cardiovascular Associates | $394.00 | Approved |
| CLM-2026-011361 | 2025-12-27 | Sunrise Imaging Center | $463.00 | 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.