CLM-2026-024070
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-08-26 at independent laboratory (POS 81). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Katherine Dean
- Member ID
- UHC-59897-08
- Date of birth
- 1958-12-09
- Identity
- Verified4 records, confidence 0.87
- Claim record
- CLMCLM-404026
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3945
- Coverage period
- 2025-05-01 to 2026-08-28
- Deductible
- $287.34 of $500.0057%
- Out-of-pocket maximum
- $416.81 of $1,500.0028%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $79.00 | $48.98 | $48.98 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $74.00 | $45.88 | $45.88 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $32.00 | $19.84 | $19.84 | $0.00 | Paid |
| Totals | $185.00 | $114.70 | $114.70 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-562178
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035595 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-08-26: MEDICARE-ADV-B (MA), effective 2025-05-01, terms 2026-08-28. | |
| Timely filing | Pass | Received 30 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Clinical Laboratories2026-08-26 09:31
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022537 | 2026-08-22 | Mesa Reference Lab | $156.00 | Denied |
| CLM-2026-022536 | 2026-08-22 | Mesa Reference Lab | $156.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.