CLM-2026-010461
Lakeside Medical Group, Internal Medicine. Service 2026-03-08 at office (POS 11). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Wei Castillo
- Member ID
- UHC-42128-21
- Date of birth
- 1960-11-18
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-414349
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2641
- Coverage period
- 2025-10-01 to 2026-03-18
- Deductible
- $698.66 of $1,000.0070%
- Out-of-pocket maximum
- $724.98 of $2,000.0036%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 2143231852
- Network
- In network
- Rendering NPI
- 6818113121
- Location
- Houston, TX · TIN 29-4552150
- Authorisation / referral
- none / REF773192
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 | $393.00 | $243.66 | — | — | DeniedCO29 |
| Totals | $393.00 | $243.66 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-800163
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007055 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-08: CORE-HMO (HMO), effective 2025-10-01, terms 2026-03-18. | |
| Timely filing | Fail | CO29 | Received 179 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 (2143231852). | |
| 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 Group2026-03-08 16:10
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-03 01:01
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 engineDenied2026-10-21 13:43Timely filing: Received 179 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029395 | 2026-05-23 | Meadow Imaging Center | $1,090.00 | Denied |
| CLM-2026-026670 | 2025-12-10 | Canyon Diagnostic Imaging | $1,518.00 | 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
Received after the timely-filing limit.