CLM-2026-002985
Lakeside Endocrine Associates, Endocrinology. Service 2026-06-17 at office (POS 11). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Brenda Clark
- Member ID
- UHC-60924-40
- Date of birth
- 1987-12-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420186
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1870
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,710.56 of $3,500.0049%
- Out-of-pocket maximum
- $2,195.12 of $7,000.0031%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 9436004995
- Location
- Mesa, AZ · TIN 27-1877258
- Authorisation / referral
- none / REF900544
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 | $400.00 | $180.00 | — | — | DeniedCO204 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $263.00 | $118.35 | — | — | DeniedCO204 |
| Totals | $663.00 | $298.35 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-933443
- 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-005181 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-17: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 14 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 | Fail | CO204 | Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Endocrine Associates2026-06-17 18:36
Patient seen for thyrotoxicosis, unspecified.
- SystemSystem: Claims system2026-07-01 03:55
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013263 | 2026-06-04 | Evergreen Primary Care Associates | $16.00 | Approved |
| CLM-2026-012353 | 2026-04-05 | Summit Clinical Laboratories | $88.00 | Approved |
| CLM-2026-032452 | 2026-01-21 | Riverside Primary Care Associates | $224.00 | 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
No out-of-network benefit on this plan.