CLM-2026-005429
Lakeside Medical Group, Family Medicine. Service 2025-12-16 at office (POS 11). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Natalie Silva
- Member ID
- UHC-19727-28
- Date of birth
- 1982-06-24
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-430307
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7877
- Coverage period
- 2024-04-01 to present
- Deductible
- $737.78 of $1,000.0074%
- Out-of-pocket maximum
- $307.35 of $3,000.0010%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4961481189
- Network
- Out of network
- Rendering NPI
- 6028922402
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $144.00 | $64.80 | — | — | DeniedCO29 |
| Totals | $144.00 | $64.80 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-330105
- 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-029746 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-16: CORE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Fail | CO29 | Received 143 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 4961481189 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2025-12-16 15:19
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-08 01:59
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 143 days after the last date of service (limit 90). Provider network: Billing provider 4961481189 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.