CLM-2026-009224
Lakeside Medical Group, Family Medicine. Service 2026-06-02 at office (POS 11). Received 2026-06-06.
Member
Resolved through the identity graph
- Member
- Priya Edwards
- Member ID
- UHC-25800-96
- Date of birth
- 1939-06-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416036
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5101
- Coverage period
- 2025-03-01 to 2026-03-23
- Deductible
- $91.85 of $1,500.006%
- Out-of-pocket maximum
- $369.10 of $6,000.006%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3004199154
- Network
- Out of network
- Rendering NPI
- 3798957528
- Location
- Atlanta, GA · TIN 59-2183874
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $242.00 | $108.90 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $259.00 | $116.55 | — | — | DeniedCO27 |
| Totals | $501.00 | $225.45 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-802504
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033842 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-02 is after coverage terminated on 2026-03-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 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 | Fail | CO204 | Billing provider 3004199154 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2026-06-02 11:30
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-06 01:10
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 2026-06-02 is after coverage terminated on 2026-03-23. Provider network: Billing provider 3004199154 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013618 | 2026-08-04 | Summit Clinical Laboratories | $165.00 | 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.