CLM-2026-025341
Harbor Reference Lab, Clinical Laboratory. Service 2026-06-15 at independent laboratory (POS 81). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Mateo Simpson
- Member ID
- UHC-48188-73
- Date of birth
- 1998-02-15
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-432784
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0660
- Coverage period
- 2021-03-01 to present
- Deductible
- $5.57 of $1,500.000%
- Out-of-pocket maximum
- $1,099.91 of $4,500.0024%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4121885428
- Network
- In network
- Rendering NPI
- 4121885428
- Location
- Tempe, AZ · TIN 21-1131562
- Authorisation / referral
- none / REF748615
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 | $47.00 | $29.14 | $29.14 | $0.00 | Paid |
| Totals | $47.00 | $29.14 | $29.14 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-124139
- 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-028235 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-15: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 19 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 Harbor Reference Lab (4121885428). | |
| 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: Harbor Reference Lab2026-06-15 15:06
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-2026-030243 | 2026-09-01 | Meadow Primary Care Associates | $215.00 | Approved |
| CLM-2026-029927 | 2026-09-26 | Riverside Primary Care Associates | $707.00 | 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.