CLM-2026-001869
Lakeside Medical Group, Family Medicine. Service 2026-01-19 at office (POS 11). Received 2026-06-13.
Member
Resolved through the identity graph
- Member
- Peter Ferguson
- Member ID
- UHC-45310-05
- Date of birth
- 1948-03-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421438
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0108
- Coverage period
- 2023-06-01 to present
- Deductible
- $431.67 of $1,000.0043%
- Out-of-pocket maximum
- $1,370.53 of $3,000.0046%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6025022396
- Network
- In network
- Rendering NPI
- 2812644450
- Location
- Houston, TX · TIN 83-6077797
- 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 | 36415 | Venipuncture | — | 1 | 1 | $14.00 | $8.68 | — | — | DeniedCO29 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $208.00 | $128.96 | — | — | DeniedCO29 |
| Totals | $222.00 | $137.64 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-318394
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008428 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-19: MEDICARE-ADV-B (MA), effective 2023-06-01. | |
| Timely filing | Fail | CO29 | Received 145 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (6025022396). | |
| 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 Medical Group2026-01-19 16:29
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-06-13 01:27
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 145 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.