CLM-2026-007334
Lakeside Medical Group, Family Medicine. Service 2026-01-23 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- William Bradley
- Member ID
- UHC-47454-98
- Date of birth
- 1938-04-02
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-428413
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5302
- Coverage period
- 2024-01-01 to present
- Deductible
- $242.32 of $1,000.0024%
- Out-of-pocket maximum
- $61.96 of $2,000.003%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 6314053433
- Location
- San Diego, CA · TIN 83-7560587
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $215.00 | $133.30 | — | — | DeniedCO29 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $303.00 | $187.86 | — | — | DeniedCO29 |
| Totals | $518.00 | $321.16 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-579585
- 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-038556 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-01-23: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Fail | CO29 | Received 204 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 Medical Group (3911891331). | |
| 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 Group2026-01-23 17:14
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-08-15 05:04
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 engineDenied2026-10-22 12:44Timely filing: Received 204 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024650 | 2026-07-12 | Pinecrest Primary Care Associates | $309.00 | 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
Received after the timely-filing limit.