CLM-2026-003690
Lakeside Medical Group, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-06-03.
Member
Resolved through the identity graph
- Member
- David Chapman
- Member ID
- UHC-21154-82
- Date of birth
- 1956-09-28
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-416861
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8693
- Coverage period
- 2025-04-01 to present
- Deductible
- $454.59 of $1,500.0030%
- Out-of-pocket maximum
- $539.52 of $3,000.0018%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4775513755
- Network
- In network
- Rendering NPI
- 6775817185
- Location
- Dallas, TX · TIN 51-2524013
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $309.00 | $191.58 | $25.00 | $166.58 | Paid |
| Totals | $309.00 | $191.58 | $25.00 | $166.58 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-782780
- 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-033510 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-12: SELECT-EPO (EPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 22 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 Medical Group (4775513755). | |
| 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 Group2026-05-12 10:28
Patient seen for essential (primary) hypertension. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-03 00:40
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-782780.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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-2026-016298 | 2026-05-19 | Northgate Medical Group | $317.00 | Approved |
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
Authorisation must be confirmed with UM before payment.