CLM-2026-025570
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-04-26 at independent laboratory (POS 81). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Andrea Alvarado
- Member ID
- UHC-47319-34
- Date of birth
- 2001-04-04
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-403990
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5889
- Coverage period
- 2021-06-01 to present
- Deductible
- $780.47 of $1,000.0078%
- Out-of-pocket maximum
- $789.64 of $2,000.0039%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7794266271
- Network
- In network
- Rendering NPI
- 8593662793 (Lakeside Reference Lab)
- 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 | $40.00 | $24.80 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $80.00 | $49.60 | — | — | Review |
| Totals | $120.00 | $74.40 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-894477
- 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-011877 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-04-26: SELECT-EPO (EPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-025569, billed by a different provider. Possible duplicate |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Clinical Laboratories2026-04-26 14:16
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-01 00:13
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-01 09:18
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-025569, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025569 | 2026-04-26 | Lakeside Reference Lab | $120.00 | 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.