CLM-2026-033922
Summit Reference Lab, Clinical Laboratory. Service 2026-07-07 at independent laboratory (POS 81). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Michael Weber
- Member ID
- UHC-63996-85
- Date of birth
- 1950-12-27
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-432157
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0730
- Coverage period
- 2025-06-01 to present
- Deductible
- $67.76 of $500.0014%
- Out-of-pocket maximum
- $832.05 of $2,000.0042%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2797853506
- Network
- In network
- Rendering NPI
- 2797853506
- Location
- Nashville, TN · TIN 64-6425854
- 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 | $71.00 | $44.02 | $44.02 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $53.00 | $32.86 | $32.86 | $0.00 | Paid |
| Totals | $124.00 | $76.88 | $76.88 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-515377
- 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-038266 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-07: CHOICE-PLUS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 6 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 Summit Reference Lab (2797853506). | |
| 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: Summit Reference Lab2026-07-07 09:50
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.