CLM-2026-012107
Lakeside Medical Group, Family Medicine. Service 2025-12-19 at office (POS 11). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Andrea Wagner
- Member ID
- UHC-53110-13
- Date of birth
- 1940-02-15
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-427752
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6663
- Coverage period
- 2024-08-01 to present
- Deductible
- $140.31 of $1,000.0014%
- Out-of-pocket maximum
- $318.30 of $4,000.008%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 5057047172
- Location
- San Diego, CA · TIN 83-7560587
- 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 | 59 | 1 | 1 | $211.00 | $130.82 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | 59 | 1 | 1 | $280.00 | $173.60 | — | — | Review |
| Totals | $491.00 | $304.42 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-961496
- 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-001345 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-19: NULL (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 17 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 (3911891331). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2025-12-19 09:26
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-05 01:24
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-961496.pdf4 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-21 14:14The claim is for an office visit and a preventive visit, both of which are supported by the diagnosis of hyperlipidemia. The provider is in-network, and the member is eligible. The use of modifier 59 is justified by the operative note, which documents procedures at two distinct anatomical sites. The claim is within the auto-adjudication ceiling and all required documentation is present.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · a9816732
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an office visit and a preventive visit, both of which are supported by the diagnosis of hyperlipidemia. The provider is in-network, and the member is eligible. The use of modifier 59 is justified by the operative note, which documents procedures at two distinct anatomical sites. The claim is within the auto-adjudication ceiling and all required documentation is present.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.