CLM-2026-007825
Lakeside Medical Group, Family Medicine. Service 2026-06-25 at office (POS 11). Received 2026-08-02.
Member
Resolved through the identity graph
- Member
- Timothy Hernandez
- Member ID
- UHC-76166-29
- Date of birth
- 1991-07-06
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-401110
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9769
- Coverage period
- 2025-01-01 to 2026-06-19
- Deductible
- $1,480.83 of $2,500.0059%
- Out-of-pocket maximum
- $2,814.48 of $7,500.0038%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4775513755
- Network
- In network
- Rendering NPI
- 3686754979
- 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 | 90471 | Immunization administration | — | 1 | 1 | $39.00 | $24.18 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $308.00 | $190.96 | — | — | DeniedCO27 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $264.00 | $163.68 | — | — | DeniedCO27 |
| Totals | $611.00 | $378.82 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-619233
- 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-002028 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-25 is after coverage terminated on 2026-06-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-06-25 11:15
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-02 03:46
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-02 08:44
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-25 is after coverage terminated on 2026-06-19.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015474 | 2026-03-10 | Valley Heart Institute | $9,474.00 | 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
Service after coverage termination.