CLM-2026-004403
Lakeside Medical Group, Internal Medicine. Service 2026-02-20 at office (POS 11). Received 2026-03-26.
Member
Resolved through the identity graph
- Member
- Arthur Torres
- Member ID
- UHC-83889-10
- Date of birth
- 2005-05-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-413485
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group -
- Coverage period
- 2024-11-01 to present
- Deductible
- $273.73 of $1,000.0027%
- Out-of-pocket maximum
- $1,722.13 of $4,000.0043%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 2697451526
- Location
- Tampa, FL · TIN 85-1984822
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $353.00 | $218.86 | — | — | DeniedCO18 |
| Totals | $353.00 | $218.86 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-511229
- 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-019719 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004402: 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 Medical Group (3228212296). | |
| 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 Group2026-02-20 14:51
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-03-26 06:18
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-004402: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011994 | 2026-03-16 | Harbor Clinical Laboratories | $169.00 | Denied |
| CLM-2026-031187 | 2026-02-27 | Canyon Internal Medicine Associates | $85.00 | Denied |
| CLM-2026-004402 | 2026-02-20 | Lakeside Medical Group | $353.00 | 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.