CLM-2026-024486
Unity Reference Lab, Clinical Laboratory. Service 2026-05-13 at independent laboratory (POS 81). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Ethan Foster
- Member ID
- UHC-36897-68
- Date of birth
- 1941-08-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426495
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9592
- Coverage period
- 2022-08-01 to present
- Deductible
- $819.38 of $3,500.0023%
- Out-of-pocket maximum
- $2,887.48 of $7,000.0041%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4863274690
- Network
- In network
- Rendering NPI
- 6068288409 (Pinecrest Clinical Laboratories)
- Location
- Houston, TX · TIN 64-5514010
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $68.00 | $42.16 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $49.00 | $30.38 | — | — | Review |
| Totals | $117.00 | $72.54 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-551993
- 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-014856 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-13: MEDICARE-ADV-A (MA), effective 2022-08-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-024485, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Reference Lab (4863274690). | |
| 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 Lab2026-05-13 09:11
Patient seen for essential (primary) hypertension. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-29 05:32
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-29 09:51
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 engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-024485, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024485 | 2026-05-13 | Pinecrest Clinical Laboratories | $117.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.