CLM-2026-000068
Lakeside Endocrine Associates, Endocrinology. Service 2026-01-15 at office (POS 11). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Camila Sims
- Member ID
- UHC-37140-99
- Date of birth
- 1950-08-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-407989
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6100
- Coverage period
- 2021-06-01 to present
- Deductible
- $2,819.98 of $3,500.0081%
- Out-of-pocket maximum
- $583.77 of $7,000.008%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 4550491177
- Location
- Mesa, AZ · TIN 27-1877258
- 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 | $28.35 | — | — | DeniedCO204 |
| 2 | 95251 | Continuous glucose monitoring, analysis | 25 | 1 | 2 | $126.00 | $56.70 | — | — | DeniedCO204 |
| Totals | $189.00 | $85.05 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-883918
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013486 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-15: SELECT-EPO (EPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 32 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 | Fail | CO204 | Billing provider 5648838790 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Lakeside Endocrine Associates2026-01-15 18:45
Patient seen for hypothyroidism, unspecified.
- SystemSystem: Claims system2026-02-16 04:02
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5648838790 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.