Claims workbench/CLM-2026-006029

Professional claim · CMS-1500 · Provider portal

CLM-2026-006029

Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-04-29 at office (POS 11). Received 2026-09-19.

Denied

Billed

$341.00

2 lines

Allowed

$211.42

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Luis Dominguez
Member ID: UHC-85052-29
Date of birth: 1955-05-24
Identity: Verified5 records, confidence 1.00
Claim record: CLMCLM-425740
Relationship: Child, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-7179
Coverage period: 2024-06-01 to present
Deductible: $357.05 of $3,500.0010%
Out-of-pocket maximum: $2,125.73 of $7,000.0030%
Copays: office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Internal Medicine Associates
Internal Medicine · taxonomy 207R00000X
NPI: 6735813951
Network: In network
Rendering NPI: 1146092881
Location: Denver, CO · TIN 58-6102170
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	93000	Electrocardiogram with interpretation	—	1	1	$113.00	$70.06	—	—	DeniedCO29
2	99214	Office visit, established patient, moderate complexity	—	1	1,2	$228.00	$141.36	—	—	DeniedCO29
Totals						$341.00	$211.42	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal
2. E11.65 Type 2 diabetes mellitus with hyperglycemia

Claim header

Patient account: PA-925302
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-016468 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-04-29: SELECT-EPO (EPO), effective 2024-06-01.
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	Pass		In-network provider Lakeside Internal Medicine Associates (6735813951).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Internal Medicine Associates2026-04-29 14:00
Patient seen for essential (primary) hypertension.
SystemSystem: Claims system2026-09-19 05:02
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-19 08:17
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 143 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-018684	2026-08-12	Valley Digestive Health Center	$2,727.00	Approved
CLM-2026-029813	2026-03-03	Valley Community Hospital	$2,629.00	Needs review
CLM-2026-018172	2026-01-25	Meadow Heart Institute	$9,295.00	Denied
CLM-2026-018171	2026-01-25	Meadow Heart Institute	$9,295.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity