CLM-2026-032193
Unity Clinical Laboratories, Clinical Laboratory. Service 2026-02-11 at independent laboratory (POS 81). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Wei Hunt
- Member ID
- UHC-22166-98
- Date of birth
- 1982-02-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-411690
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5127
- Coverage period
- 2024-09-01 to present
- Deductible
- $44.83 of $2,500.002%
- Out-of-pocket maximum
- $1,517.27 of $7,500.0020%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1092116486
- Network
- In network
- Rendering NPI
- 1092116486
- Location
- Houston, TX · TIN 34-8016251
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| 2 | 87086 | Urine culture | 25 | 1 | 1 | $41.00 | $25.42 | — | — | Review |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 2 | $53.00 | $32.86 | — | — | Review |
| Totals | $131.00 | $81.22 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-610405
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022388 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-11: CHOICE-PLUS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 44 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 Clinical Laboratories (1092116486). | |
| 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: “Established patient presents with urinary tract infection, site not specified; symptoms re”. 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 Clinical Laboratories2026-02-11 14:46
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-27 01:01
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-27 13:59
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with urinary tract infection, site not specified; symptoms re”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.