CLM-2026-008203
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-07-22 at office (POS 11). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Christine Wagner
- Member ID
- UHC-57021-61
- Date of birth
- 1989-02-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425817
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7795
- Coverage period
- 2024-04-01 to present
- Deductible
- $2,472.16 of $3,500.0071%
- Out-of-pocket maximum
- $4,875.34 of $10,500.0046%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6735813951
- Network
- In network
- Rendering NPI
- 9968893914
- Location
- Denver, CO · TIN 58-6102170
- Authorisation / referral
- none / REF249217
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 | $72.00 | $44.64 | $40.00 | $4.64 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $217.00 | $134.54 | $0.00 | $134.54 | Paid |
| Totals | $289.00 | $179.18 | $40.00 | $139.18 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-475402
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007869 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-22: NAVIGATE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 37 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 (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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Internal Medicine Associates2026-07-22 11:34
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001242 | 2026-07-25 | Sunrise Clinical Laboratories | $106.00 | Approved |
| CLM-2026-034628 | 2026-01-29 | Desert Primary Care Associates | $41.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.