Professional claim · CMS-1500 · EDI 837P
CLM-2026-024668
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-01-26 at independent laboratory (POS 81). Received 2026-02-18.
Approved
Billed
$166.00
3 lines
Allowed
$102.92
contract rate applied
Plan pays
$0.00
approved
Member owes
$102.92
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Grace Hayes
- Member ID
- UHC-70367-18
- Date of birth
- 1964-09-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407248
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0743
- Coverage period
- 2023-01-01 to present
- Deductible
- $26.86 of $3,500.001%
- Out-of-pocket maximum
- $1,660.97 of $10,500.0016%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7794266271
- Network
- In network
- Rendering NPI
- 7794266271
- Location
- Austin, TX · TIN 55-3185776
- 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 | 87086 | Urine culture | — | 1 | 1 | $51.00 | $31.62 | $31.62 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $49.00 | $30.38 | $30.38 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $66.00 | $40.92 | $40.92 | $0.00 | Paid |
| Totals | $166.00 | $102.92 | $102.92 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-923245
- 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-014001 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-A (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 23 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 (7794266271). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Clinical Laboratories2026-01-26 14:56
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$166.00
Plan discount
$63.08
contracted rate
Plan paid
$0.00
You may owe
$102.92
copay, deductible and coinsurance
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-2026-030568 | 2026-07-28 | Desert Internal Medicine Associates | $120.00 | Needs review |
| CLM-2026-030567 | 2026-07-28 | Heritage Medical Group | $120.00 | Approved |
| CLM-2026-005232 | 2026-04-03 | Northgate Bone and Joint Center | $170.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.