CLM-2026-028245
Unity Reference Lab, Clinical Laboratory. Service 2025-12-19 at independent laboratory (POS 81). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Daniel Vargas
- Member ID
- UHC-13090-50
- Date of birth
- 1964-04-22
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-428039
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1519
- Coverage period
- 2023-01-01 to present
- Deductible
- $295.09 of $500.0059%
- Out-of-pocket maximum
- $311.37 of $2,000.0016%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4372283836
- Network
- In network
- Rendering NPI
- 4372283836
- Location
- Phoenix, AZ · TIN 58-9749325
- 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 | $56.00 | $34.72 | — | — | Review |
| 2 | 87086 | Urine culture | — | 1 | 1 | $51.00 | $31.62 | — | — | Review |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $59.00 | $36.58 | — | — | Review |
| Totals | $166.00 | $102.92 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-709615
- 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-002672 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-19: CHOICE-PLUS-PPO (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 21 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 Unity Reference Lab (4372283836). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Reference Lab2025-12-19 18:14
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-09 01:54
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
- AI recommendationPended2026-10-21 14:15The claim has been flagged for incomplete documentation (CO16). The clinical note indicates that the plan was discussed and medications were reconciled, but the note is dictated and the signature is pending. Additionally, a development letter has been sent to the provider for the missing signature. The claim will be pended until the documentation is complete.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · fc4afec7
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim has been flagged for incomplete documentation (CO16). The clinical note indicates that the plan was discussed and medications were reconciled, but the note is dictated and the signature is pending. Additionally, a development letter has been sent to the provider for the missing signature. The claim will be pended until the documentation is complete.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.