CLM-2026-005350
Lakeside Medical Group, Family Medicine. Service 2026-08-05 at office (POS 11). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Vincent Palmer
- Member ID
- UHC-31592-87
- Date of birth
- 1969-09-01
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407890
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7173
- Coverage period
- 2024-01-01 to 2026-03-07
- Deductible
- $97.79 of $1,500.007%
- Out-of-pocket maximum
- $741.92 of $3,000.0025%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4961481189
- Network
- Out of network
- Rendering NPI
- 1257914220
- Location
- Mesa, AZ · TIN 54-1409504
- 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 | 90471 | Immunization administration | — | 1 | 1 | $32.00 | $14.40 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $259.00 | $116.55 | — | — | DeniedCO27 |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $191.00 | $85.95 | — | — | DeniedCO27 |
| Totals | $482.00 | $216.90 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-279334
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-044544 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-05 is after coverage terminated on 2026-03-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Group2026-08-05 16:09
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-19 06:15
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-19 11:53
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-05 is after coverage terminated on 2026-03-07. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024846 | 2026-09-17 | Mesa Family Practice | $234.00 | Denied |
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
Service after coverage termination.