CLM-2026-004727
Lakeside Medical Group, Family Medicine. Service 2025-12-20 at office (POS 11). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Catherine Taylor
- Member ID
- UHC-40952-61
- Date of birth
- 1942-11-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428256
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8235
- Coverage period
- 2025-03-01 to present
- Deductible
- $424.74 of $1,000.0042%
- Out-of-pocket maximum
- $355.26 of $4,000.009%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6025022396
- Network
- In network
- Rendering NPI
- 5963575928
- Location
- Houston, TX · TIN 83-6077797
- 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 | 36415 | Venipuncture | — | 1 | 1 | $17.00 | $10.54 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $218.00 | $135.16 | — | — | DeniedCO18 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $297.00 | $184.14 | — | — | DeniedCO18 |
| Totals | $532.00 | $329.84 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-347516
- 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-007728 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-20: CORE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004726: 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 (6025022396). | |
| 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 Group2025-12-20 09:44
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-09 04:23
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-2026-004726: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004726 | 2025-12-20 | Lakeside Medical Group | $532.00 | 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.