CLM-2026-001057
Lakeside Internal Medicine Associates, Internal Medicine. Service 2025-12-11 at office (POS 11). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Amy Flores
- Member ID
- UHC-82844-75
- Date of birth
- 1947-08-22
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-419604
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8824
- Coverage period
- 2024-09-01 to present
- Deductible
- $94.93 of $1,000.009%
- Out-of-pocket maximum
- $1,012.30 of $4,000.0025%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 1176993339
- Location
- Denver, CO · TIN 22-9016721
- 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 | $47.00 | $29.14 | $25.00 | $4.14 | Paid |
| Totals | $47.00 | $29.14 | $25.00 | $4.14 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
- Patient account
- PA-395669
- 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-003727 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-11: MEDICARE-ADV-B (MA), effective 2024-09-01. | |
| 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 | Pass | In-network provider Lakeside Internal Medicine Associates (8566398227). | |
| 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 Associates2025-12-11 11:40
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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-2026-016004 | 2026-06-24 | Canyon Regional Medical Center | $3,996.00 | Approved |
| CLM-2026-011805 | 2026-04-28 | Sunrise Internal Medicine Associates | $289.00 | 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.