CLM-2026-031580
Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-07-19 at independent laboratory (POS 81). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Kyle Smith
- Member ID
- UHC-47052-61
- Date of birth
- 1984-10-21
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-420327
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4203
- Coverage period
- 2022-07-01 to present
- Deductible
- $233.72 of $1,000.0023%
- Out-of-pocket maximum
- $691.98 of $3,000.0023%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4514050481
- Network
- In network
- Rendering NPI
- 4514050481
- Location
- Tempe, AZ · TIN 12-2226671
- 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 | $62.00 | $38.44 | $38.44 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $61.00 | $37.82 | $37.82 | $0.00 | Paid |
| Totals | $123.00 | $76.26 | $76.26 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-176431
- 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-015444 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-19: NULL (PPO), effective 2022-07-01. | |
| 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 | Pass | In-network provider Riverside Clinical Laboratories (4514050481). | |
| 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: Riverside Clinical Laboratories2026-07-19 13:46
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008728 | 2026-07-06 | Harbor Medical Group | $510.00 | Approved |
| CLM-2026-001401 | 2026-07-15 | Harbor Diagnostic Imaging | $130.00 | Approved |
| CLM-2026-018605 | 2026-02-05 | Lakeside Digestive Health Center | $2,380.00 | Approved |
| CLM-2026-004096 | 2026-01-13 | Unity Counseling Center | $209.00 | Approved |
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.