CLM-2026-002003
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-07-04 at office (POS 11). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Nancy Tran
- Member ID
- UHC-46507-42
- Date of birth
- 1967-05-04
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-412871
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8841
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,695.66 of $3,500.0048%
- Out-of-pocket maximum
- $1,636.75 of $10,500.0016%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 2538868722
- Location
- Denver, CO · TIN 22-9016721
- Authorisation / referral
- none / REF270680
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 | $42.00 | $26.04 | — | — | DeniedCO18 |
| Totals | $42.00 | $26.04 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-931939
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040559 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-04: NAVIGATE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002002: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Associates2026-07-04 17:38
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 02:57
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-20 08:49
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-002002: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002002 | 2026-07-04 | Lakeside Internal Medicine Associates | $42.00 | Approved |
| CLM-2026-030385 | 2026-08-04 | Pinecrest Medical Group | $254.00 | Approved |
| CLM-2026-016472 | 2026-07-20 | Sunrise Clinical Laboratories | $159.00 | Approved |
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
Exact duplicate of an earlier submission.