CLM-2026-007980
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-04-16 at office (POS 11). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Ahmed Castro
- Member ID
- UHC-57979-50
- Date of birth
- 1947-09-25
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431135
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6698
- Coverage period
- 2023-05-01 to 2026-03-14
- Deductible
- $3,090.83 of $3,500.0088%
- Out-of-pocket maximum
- $412.07 of $10,500.004%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5141407317
- Network
- In network
- Rendering NPI
- 2918327448
- Location
- Charlotte, NC · TIN 14-0698276
- Authorisation / referral
- none / REF329474
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $345.00 | $213.90 | — | — | DeniedCO27 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $68.00 | $42.16 | — | — | DeniedCO27 |
| Totals | $413.00 | $256.06 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-774175
- 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-006023 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-16 is after coverage terminated on 2026-03-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 Internal Medicine Associates (5141407317). | |
| 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 Internal Medicine Associates2026-04-16 15:16
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-26 00:59
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 2026-04-16 is after coverage terminated on 2026-03-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004500 | 2026-05-05 | Mesa Clinical Laboratories | $166.00 | Denied |
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.