Professional claim · CMS-1500 · EDI 837P
CLM-2026-023985
Summit Reference Lab, Clinical Laboratory. Service 2026-09-16 at independent laboratory (POS 81). Received 2026-10-05.
ApprovedOut of network
Billed
$184.00
3 lines
Allowed
$82.80
contract rate applied
Plan pays
$0.00
approved
Member owes
$82.80
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
- Rachel Ray
- Member ID
- UHC-80386-84
- Date of birth
- 1956-09-26
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-414674
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6454
- Coverage period
- 2021-07-01 to present
- Deductible
- $386.94 of $500.0077%
- Out-of-pocket maximum
- $836.43 of $2,000.0042%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7256801888
- Network
- Out of network
- Rendering NPI
- 7256801888
- Location
- Scottsdale, AZ · TIN 41-8218808
- 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 | $69.00 | $31.05 | $31.05 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $58.00 | $26.10 | $26.10 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $57.00 | $25.65 | $25.65 | $0.00 | Paid |
| Totals | $184.00 | $82.80 | $82.80 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-590448
- 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-028717 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-16: OPTIONS-PPO (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 19 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: Summit Reference Lab2026-09-16 15:11
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$184.00
Plan discount
$101.20
out-of-network allowance
Plan paid
$0.00
You may owe
$82.80
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
No other claims.
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.