Professional claim · CMS-1500 · EDI 837P
CLM-2026-005697
Lakeside Medical Group, Family Medicine. Service 2026-01-12 at office (POS 11). Received 2026-02-13.
Approved
Billed
$299.00
2 lines
Allowed
$185.38
contract rate applied
Plan pays
$145.38
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Margaret Hughes
- Member ID
- UHC-43067-83
- Date of birth
- 1954-04-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-407972
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group -
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,331.57 of $1,500.0089%
- Out-of-pocket maximum
- $743.02 of $3,000.0025%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4775513755
- Network
- In network
- Rendering NPI
- 9634364373
- Location
- Dallas, TX · TIN 51-2524013
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $257.00 | $159.34 | $40.00 | $119.34 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| Totals | $299.00 | $185.38 | $40.00 | $145.38 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-146561
- 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-012797 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: NULL (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 32 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 Medical Group (4775513755). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-01-12 18:48
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$299.00
Plan discount
$113.62
contracted rate
Plan paid
$145.38
You may owe
$40.00
copay, deductible and coinsurance
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-2026-023442 | 2026-04-15 | Northgate Primary Care Associates | $499.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.