Professional claim · CMS-1500 · EDI 837P
CLM-2026-000307
Lakeside Medical Group, Internal Medicine. Service 2026-05-26 at office (POS 11). Received 2026-06-04.
Approved
Billed
$454.00
3 lines
Allowed
$281.48
contract rate applied
Plan pays
$261.48
approved
Member owes
$20.00
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
- Andrea Howell
- Member ID
- UHC-41300-78
- Date of birth
- 1951-10-20
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424439
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2625
- Coverage period
- 2021-06-01 to present
- Deductible
- $148.47 of $2,500.006%
- Out-of-pocket maximum
- $2,384.25 of $7,500.0032%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 2143231852
- Network
- In network
- Rendering NPI
- 8429520793
- Location
- Houston, TX · TIN 29-4552150
- Authorisation / referral
- none / REF623345
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 | $70.00 | $43.40 | $20.00 | $23.40 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $299.00 | $185.38 | $0.00 | $185.38 | Paid |
| 3 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1,2 | $85.00 | $52.70 | $0.00 | $52.70 | Paid |
| Totals | $454.00 | $281.48 | $20.00 | $261.48 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-723333
- 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-014886 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-26: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 9 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 Lakeside Medical Group (2143231852). | |
| 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: Lakeside Medical Group2026-05-26 12:09
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$454.00
Plan discount
$172.52
contracted rate
Plan paid
$261.48
You may owe
$20.00
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-2026-007967 | 2025-11-12 | Riverside Primary Care Associates | $251.00 | Denied |
| CLM-2026-033686 | 2026-03-11 | Sunrise Counseling Center | $2,675.00 | Needs review |
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.