Professional claim · CMS-1500 · Paper
CLM-2026-027750
Mesa Reference Lab, Clinical Laboratory. Service 2026-04-20 at independent laboratory (POS 81). Received 2026-05-23.
Approved
Billed
$187.00
3 lines
Allowed
$115.94
contract rate applied
Plan pays
$0.00
approved
Member owes
$115.94
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Nancy Miller
- Member ID
- UHC-43773-54
- Date of birth
- 1953-09-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432790
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6317
- Coverage period
- 2022-08-01 to present
- Deductible
- $287.51 of $1,000.0029%
- Out-of-pocket maximum
- $859.71 of $2,000.0043%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 1578442364
- Network
- In network
- Rendering NPI
- 1578442364
- Location
- Scottsdale, AZ · TIN 27-6614149
- 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 | $65.00 | $40.30 | $40.30 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1,2 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| 3 | 87086 | Urine culture | 25 | 1 | 1 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| Totals | $187.00 | $115.94 | $115.94 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-488171
- 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-013439 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-20: SELECT-EPO (EPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 33 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 Mesa Reference Lab (1578442364). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Reference Lab2026-04-20 16:12
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$187.00
Plan discount
$71.06
contracted rate
Plan paid
$0.00
You may owe
$115.94
copay, deductible and coinsurance
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-2026-034608 | 2026-06-13 | Pinecrest Medical Group | $241.00 | Approved |
| CLM-2026-027112 | 2026-04-02 | Pinecrest Bone and Joint Center | $189.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.