CLM-2026-024192
Lakeside Reference Lab, Clinical Laboratory. Service 2026-05-23 at independent laboratory (POS 81). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Julie Fernandez
- Member ID
- UHC-84577-80
- Date of birth
- 1978-03-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402294
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3571
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,092.73 of $1,500.0073%
- Out-of-pocket maximum
- $1,038.27 of $4,500.0023%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8593662793
- Network
- In network
- Rendering NPI
- 8593662793
- Location
- Austin, TX · TIN 19-8347023
- 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 | $70.00 | $43.40 | $43.40 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 2 | $35.00 | $21.70 | $21.70 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $62.00 | $38.44 | $38.44 | $0.00 | Paid |
| 4 | 85025 | Complete blood count with differential | — | 1 | 1 | $39.00 | $24.18 | $24.18 | $0.00 | Paid |
| Totals | $206.00 | $127.72 | $127.72 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-722026
- 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-028161 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: CHOICE-PLUS-PPO (PPO), effective 2025-12-01. | |
| 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 Lakeside Reference Lab (8593662793). | |
| 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: Lakeside Reference Lab2026-05-23 12:19
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-2026-006808 | 2025-10-15 | Desert Internal Medicine Associates | $314.00 | Denied |
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.