CLM-2026-027026
Pinecrest Clinical Laboratories, Clinical Laboratory. Service 2025-12-16 at independent laboratory (POS 81). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Priya Tucker
- Member ID
- UHC-26060-45
- Date of birth
- 1981-02-07
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-411742
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3235
- Coverage period
- 2025-06-01 to present
- Deductible
- $67.92 of $500.0014%
- Out-of-pocket maximum
- $796.51 of $2,000.0040%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 6068288409
- Network
- In network
- Rendering NPI
- 7794266271 (Sunrise Clinical Laboratories)
- Location
- San Diego, CA · TIN 41-0079440
- 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 | 80061 | Lipid panel | — | 1 | 1 | $64.00 | $39.68 | — | — | Review |
| Totals | $64.00 | $39.68 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-613632
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001814 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-16: MEDICARE-ADV-B (MA), effective 2025-06-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-027025, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Clinical Laboratories (6068288409). | |
| 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: Pinecrest Clinical Laboratories2025-12-16 11:13
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-01-12 06:28
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-12 11:10
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-027025, billed by a different provider.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:43 · 1749ac5d
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010003 | 2026-01-22 | Sunrise Community Hospital | $2,296.00 | Approved |
| CLM-2026-010697 | 2025-07-24 | Unity Internal Medicine Associates | $332.00 | Denied |
| CLM-2026-011714 | 2026-01-19 | Mesa Orthopedic Specialists | $48,085.00 | Denied |
| CLM-2026-027025 | 2025-12-16 | Sunrise Clinical Laboratories | $64.00 | 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.