CLM-2026-026718
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-08-05 at independent laboratory (POS 81). Received 2026-08-25.
Member
Resolved through the identity graph
- Member
- Alexis Fox
- Member ID
- UHC-32649-36
- Date of birth
- 2007-04-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-405159
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0870
- Coverage period
- 2021-02-01 to present
- Deductible
- $846.46 of $1,000.0085%
- Out-of-pocket maximum
- $871.13 of $3,000.0029%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $79.00 | $48.98 | $48.98 | $0.00 | Paid |
| Totals | $79.00 | $48.98 | $48.98 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-635971
- 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-015084 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: CHOICE-PLUS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 20 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 (1737179139). | |
| 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 Laboratories2026-08-05 18:23
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-2026-003890 | 2026-09-27 | Riverside Clinical Laboratories | $38.00 | Approved |
| CLM-2026-017574 | 2026-04-17 | Lakeside Skin Care Associates | $685.00 | Approved |
| CLM-2026-024570 | 2026-02-20 | Lakeside Reference Lab | $61.00 | 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.