CLM-2026-033454
Sunrise Clinical Laboratories, Clinical Laboratory. Service 2026-05-21 at independent laboratory (POS 81). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Wei Cooper
- Member ID
- UHC-84241-56
- Date of birth
- 1953-10-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-431429
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3458
- Coverage period
- 2024-02-01 to 2026-01-19
- Deductible
- $658.34 of $1,500.0044%
- Out-of-pocket maximum
- $1,439.45 of $4,500.0032%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 1737179139
- Network
- In network
- Rendering NPI
- 1737179139
- Location
- Austin, TX · TIN 90-0370189
- 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 | 87086 | Urine culture | — | 1 | 1 | $39.00 | $24.18 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 2 | $53.00 | $32.86 | — | — | DeniedCO27 |
| Totals | $92.00 | $57.04 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-684625
- 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-010333 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-21 is after coverage terminated on 2026-01-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 Sunrise Clinical Laboratories (1737179139). | |
| 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: Sunrise Clinical Laboratories2026-05-21 14:30
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-01 03:53
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-01 11:21
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-21 is after coverage terminated on 2026-01-19.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002935 | 2026-04-21 | Desert Family Practice | $214.00 | Denied |
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.