CLM-2026-023857
Unity Reference Lab, Clinical Laboratory. Service 2026-07-22 at independent laboratory (POS 81). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Heather Nelson
- Member ID
- UHC-40310-14
- Date of birth
- 1950-11-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414322
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3393
- Coverage period
- 2023-08-01 to 2026-02-06
- Deductible
- $19.98 of $1,500.001%
- Out-of-pocket maximum
- $1,222.80 of $6,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4372283836
- Network
- In network
- Rendering NPI
- 4372283836
- Location
- Phoenix, AZ · TIN 58-9749325
- 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 | $61.00 | $37.82 | — | — | DeniedCO27 |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 2 | $63.00 | $39.06 | — | — | DeniedCO27 |
| Totals | $124.00 | $76.88 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-823618
- 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-018209 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Unity Reference Lab (4372283836). | |
| 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: Unity Reference Lab2026-07-22 15:01
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-12 04:32
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-12 16:36
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-02-06.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016991 | 2026-01-29 | Harbor Rehabilitation Center | $195.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.