CLM-2026-029054
Desert Reference Lab, Clinical Laboratory. Service 2026-01-30 at independent laboratory (POS 81). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Becky Espinoza
- Member ID
- UHC-43207-29
- Date of birth
- 1999-07-27
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-421027
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7508
- Coverage period
- 2025-11-01 to present
- Deductible
- $424.53 of $1,500.0028%
- Out-of-pocket maximum
- $2,735.79 of $6,000.0046%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 5138952598
- Network
- Out of network
- Rendering NPI
- 5138952598
- Location
- Mesa, AZ · TIN 53-1049966
- 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 | $69.00 | $31.05 | $31.05 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $37.00 | $16.65 | $16.65 | $0.00 | Paid |
| 3 | 87086 | Urine culture | — | 1 | 2 | $40.00 | $18.00 | $18.00 | $0.00 | Paid |
| 4 | 83036 | Hemoglobin A1c | — | 1 | 2 | $59.00 | $26.55 | $26.55 | $0.00 | Paid |
| Totals | $205.00 | $92.25 | $92.25 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-398484
- 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-004942 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-30: OPTIONS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 43 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Desert Reference Lab2026-01-30 12:29
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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Clean claim, priced at contract rate.