Professional claim · CMS-1500 · Paper
CLM-2026-032614
Evergreen Clinical Laboratories, Clinical Laboratory. Service 2026-01-01 at independent laboratory (POS 81). Received 2026-01-18.
Approved
Billed
$147.00
3 lines
Allowed
$91.14
contract rate applied
Plan pays
$0.00
approved
Member owes
$91.14
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Kelly Lucas
- Member ID
- UHC-15635-05
- Date of birth
- 1947-12-15
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-423177
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0972
- Coverage period
- 2023-02-01 to present
- Deductible
- $1,025.55 of $2,500.0041%
- Out-of-pocket maximum
- $4,629.53 of $10,000.0046%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 5984537261
- Network
- In network
- Rendering NPI
- 5984537261
- Location
- Mesa, AZ · TIN 92-1302766
- Authorisation / referral
- none / REF151859
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 | $49.00 | $30.38 | $30.38 | $0.00 | Paid |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $47.00 | $29.14 | $29.14 | $0.00 | Paid |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $51.00 | $31.62 | $31.62 | $0.00 | Paid |
| Totals | $147.00 | $91.14 | $91.14 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. N39.0 Urinary tract infection, site not specified
Claim header
- Patient account
- PA-624446
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005452 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-01: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 17 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 Evergreen Clinical Laboratories (5984537261). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Clinical Laboratories2026-01-01 17:46
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$147.00
Plan discount
$55.86
contracted rate
Plan paid
$0.00
You may owe
$91.14
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025719 | 2026-07-17 | Valley Reference Lab | $40.00 | Denied |
| CLM-2026-025718 | 2026-07-17 | Valley Reference Lab | $40.00 | Approved |
| CLM-2026-010329 | 2026-02-27 | Evergreen Family Practice | $582.00 | Approved |
| CLM-2026-032615 | 2026-01-01 | Canyon Reference Lab | $147.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.