Claims workbench/CLM-2026-001609

Professional claim · CMS-1500 · Provider portal

CLM-2026-001609

Lakeside Medical Group, Family Medicine. Service 2026-06-19 at office (POS 11). Received 2026-07-19.

DeniedOut of network

Billed

$506.00

3 lines

Allowed

$227.70

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Albert Banks
Member ID: UHC-93683-76
Date of birth: 1998-02-12
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-406533
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: NULL PPO group GRP-0583
Coverage period: 2023-02-01 to 2026-04-16
Deductible: $1,559.19 of $2,500.0062%
Out-of-pocket maximum: $1,889.47 of $7,500.0025%
Copays: office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits: 21 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 3004199154
Network: Out of network
Rendering NPI: 3758461115
Location: Atlanta, GA · TIN 59-2183874
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	99213	Office visit, established patient, low complexity	—	1	1	$173.00	$77.85	—	—	DeniedCO27
2	90471	Immunization administration	—	1	1	$29.00	$13.05	—	—	DeniedCO27
3	99395	Preventive visit, 18-39 years	—	1	1	$304.00	$136.80	—	—	DeniedCO27
Totals						$506.00	$227.70	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. Z00.00 Encounter for general adult medical examination without abnormal findings
3. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-271998
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-004689 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-06-19 is after coverage terminated on 2026-04-16. Expenses incurred after coverage terminated
Timely filing	Pass		Received 30 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Medical Group2026-06-19 15:55
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-07-19 04:05
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-19 15:50
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-06-19 is after coverage terminated on 2026-04-16. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-010622	2026-06-30	Sunrise Medical Group	$31.00	Denied

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity