CLM-2026-024133
Unity Reference Lab, Clinical Laboratory. Service 2026-04-18 at independent laboratory (POS 81). Received 2026-08-06.
Member
Resolved through the identity graph
- Member
- Donald Santiago
- Member ID
- UHC-70607-32
- Date of birth
- 2003-08-02
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-425791
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9504
- Coverage period
- 2021-01-01 to present
- Deductible
- $393.90 of $500.0079%
- Out-of-pocket maximum
- $147.33 of $2,000.007%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 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 / REF146570
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $77.00 | $47.74 | — | — | DeniedCO29 |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $76.00 | $47.12 | — | — | DeniedCO29 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $64.00 | $39.68 | — | — | DeniedCO29 |
| Totals | $217.00 | $134.54 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-626723
- 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-014023 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-04-18: CORE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Fail | CO29 | Received 110 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Lab2026-04-18 11:14
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-06 06:00
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-06 11:20
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 engineDenied2026-10-22 12:44Timely filing: Received 110 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.