CLM-2026-024198
Evergreen Clinical Laboratories, Clinical Laboratory. Service 2026-10-05 at independent laboratory (POS 81). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Betty Gomez
- Member ID
- UHC-79259-25
- Date of birth
- 1977-06-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422993
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5576
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,093.34 of $3,500.0031%
- Out-of-pocket maximum
- $686.38 of $7,000.0010%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5984537261
- Network
- In network
- Rendering NPI
- 5984537261
- Location
- Mesa, AZ · TIN 92-1302766
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $66.00 | $40.92 | $40.92 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $40.00 | $24.80 | $24.80 | $0.00 | Paid |
| Totals | $106.00 | $65.72 | $65.72 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-824194
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018202 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-05: MEDICARE-ADV-B (MA), effective 2024-07-01. | |
| Timely filing | Pass | Received 3 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 Evergreen Clinical Laboratories (5984537261). | |
| 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: Evergreen Clinical Laboratories2026-10-05 16:03
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007458 | 2026-07-14 | Northgate Counseling Center | $222.00 | 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.