CLM-2026-003867
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-05-17 at office (POS 11). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Grace Harper
- Member ID
- UHC-75926-22
- Date of birth
- 1981-06-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409858
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4172
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,288.26 of $3,500.0037%
- Out-of-pocket maximum
- $6,767.21 of $14,000.0048%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 6996605153
- Location
- Denver, CO · TIN 22-9016721
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $80.00 | $49.60 | $30.00 | $19.60 | Paid |
| Totals | $80.00 | $49.60 | $30.00 | $19.60 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-986904
- 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-009406 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-17: MEDICARE-ADV-A (MA), effective 2022-08-01. | |
| Timely filing | Pass | Received 11 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 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 Associates2026-05-17 18:27
Patient seen for unspecified atrial fibrillation. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-28 02:55
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-986904.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-2026-027268 | 2026-06-16 | Sunrise Counseling Center | $232.00 | 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.