CLM-2026-001359
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-05-18 at office (POS 11). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Catherine Peterson
- Member ID
- UHC-33326-02
- Date of birth
- 1954-08-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-421879
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3840
- Coverage period
- 2021-09-01 to present
- Deductible
- $2,964.55 of $3,500.0085%
- Out-of-pocket maximum
- $2,561.55 of $14,000.0018%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 2378440780
- Location
- Los Angeles, CA · TIN 18-5876521
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $398.00 | $246.76 | $40.00 | $206.76 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $316.00 | $195.92 | $0.00 | $195.92 | Paid |
| Totals | $714.00 | $442.68 | $40.00 | $402.68 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-350233
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031524 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-18: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| 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 (6644545769). | |
| 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 Associates2026-05-18 12:26
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001360 | 2026-05-18 | Lakeside Internal Medicine Associates | $714.00 | Needs review |
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.