CLM-2026-024684
Desert Reference Lab, Clinical Laboratory. Service 2026-07-12 at independent laboratory (POS 81). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Charles Burton
- Member ID
- UHC-47128-17
- Date of birth
- 1975-07-25
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-407962
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2740
- Coverage period
- 2025-07-01 to present
- Deductible
- $405.48 of $500.0081%
- Out-of-pocket maximum
- $679.65 of $1,500.0045%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5138952598
- Network
- Out of network
- Rendering NPI
- 5138952598
- Location
- Mesa, AZ · TIN 53-1049966
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $65.00 | $29.25 | $29.25 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 2 | $34.00 | $15.30 | $15.30 | $0.00 | Paid |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $41.00 | $18.45 | $18.45 | $0.00 | Paid |
| Totals | $140.00 | $63.00 | $63.00 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-808119
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013626 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-12: MEDICARE-ADV-A (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 35 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Desert Reference Lab2026-07-12 11:56
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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018964 | 2026-09-07 | Riverside Imaging Center | $342.00 | Denied |
| CLM-2026-018963 | 2026-09-07 | Riverside Imaging Center | $342.00 | 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.