CLM-2026-026016
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-01-30 at independent laboratory (POS 81). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Albert Ellis
- Member ID
- UHC-85432-06
- Date of birth
- 2001-08-08
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-419377
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0344
- Coverage period
- 2025-08-01 to present
- Deductible
- $100.38 of $500.0020%
- Out-of-pocket maximum
- $640.32 of $1,500.0043%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 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 / REF450265
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 | $30.00 | $18.60 | $18.60 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $65.00 | $40.30 | $40.30 | $0.00 | Paid |
| Totals | $95.00 | $58.90 | $58.90 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-826013
- 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-005701 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-30: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 14 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Clinical Laboratories2026-01-30 10:06
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-2026-011317 | 2026-05-01 | Mesa Diabetes Center | $524.00 | Approved |
| CLM-2026-022205 | 2026-04-28 | Unity Bone and Joint Center | $29,679.00 | Needs review |
| CLM-2026-004637 | 2026-01-17 | Northgate Bone and Joint Center | $272.00 | Denied |
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.