CLM-2026-032974
Unity Clinical Laboratories, Clinical Laboratory. Service 2026-06-14 at independent laboratory (POS 81). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Joyce Garza
- Member ID
- UHC-40324-56
- Date of birth
- 1970-06-04
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-420050
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-2340
- Coverage period
- 2021-02-01 to 2026-05-11
- Deductible
- $33.76 of $500.007%
- Out-of-pocket maximum
- $165.21 of $1,000.0017%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | 25 | 1 | 1,2 | $32.00 | $19.84 | — | — | DeniedCO27 |
| 3 | 87086 | Urine culture | — | 1 | 2 | $52.00 | $32.24 | — | — | DeniedCO27 |
| Totals | $147.00 | $91.14 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-836555
- 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-004962 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-14 is after coverage terminated on 2026-05-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Clinical Laboratories2026-06-14 10:47
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-19 00:27
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-14 is after coverage terminated on 2026-05-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024379 | 2026-01-11 | Heritage Primary Care Associates | $315.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.