CLM-2026-028977
Cornerstone Reference Lab, Clinical Laboratory. Service 2026-03-08 at independent laboratory (POS 81). Received 2026-03-16.
Member
Resolved through the identity graph
- Member
- Ryan Larson
- Member ID
- UHC-84428-67
- Date of birth
- 1957-01-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406517
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5061
- Coverage period
- 2024-02-01 to present
- Deductible
- $811.49 of $1,500.0054%
- Out-of-pocket maximum
- $1,124.48 of $3,000.0037%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4740334576
- Network
- In network
- Rendering NPI
- 4740334576
- Location
- Mesa, AZ · TIN 57-0560500
- 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 | $79.00 | $48.98 | $48.98 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $53.00 | $32.86 | $32.86 | $0.00 | Paid |
| Totals | $132.00 | $81.84 | $81.84 | $0.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-255282
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019984 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-08: MEDICARE-ADV-B (MA), effective 2024-02-01. | |
| Timely filing | Pass | Received 8 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 Cornerstone Reference Lab (4740334576). | |
| 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: Cornerstone Reference Lab2026-03-08 15:03
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-16 04:01
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-255282.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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
Authorisation must be confirmed with UM before payment.