CLM-2026-000793
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-07-04 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Brittany Lucas
- Member ID
- UHC-42291-53
- Date of birth
- 2000-03-27
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-413032
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2696
- Coverage period
- 2021-11-01 to present
- Deductible
- $290.00 of $1,500.0019%
- Out-of-pocket maximum
- $2,888.85 of $6,000.0048%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6735813951
- Network
- In network
- Rendering NPI
- 2976195794
- Location
- Denver, CO · TIN 58-6102170
- Authorisation / referral
- none / REF279691
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $113.00 | $70.06 | $25.00 | $45.06 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $281.00 | $174.22 | $0.00 | $174.22 | Paid |
| Totals | $394.00 | $244.28 | $25.00 | $219.28 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-431811
- 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-006797 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-04: CORE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 42 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 Internal Medicine Associates (6735813951). | |
| 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 Internal Medicine Associates2026-07-04 18:32
Patient seen for chronic kidney disease, stage 3 unspecified.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015286 | 2025-12-24 | Meadow Primary Care Associates | $229.00 | Approved |
| CLM-2026-016793 | 2026-01-01 | Sunrise Dermatology Clinic | $1,146.00 | Approved |
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.