Professional claim · CMS-1500 · Provider portal
CLM-2026-012309
Lakeside Medical Group, Family Medicine. Service 2026-06-04 at office (POS 11). Received 2026-06-24.
Approved
Billed
$354.00
2 lines
Allowed
$219.48
contract rate applied
Plan pays
$189.48
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Michael Alvarado
- Member ID
- UHC-14405-57
- Date of birth
- 1981-06-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408427
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1323
- Coverage period
- 2022-07-01 to present
- Deductible
- $490.30 of $1,000.0049%
- Out-of-pocket maximum
- $60.59 of $4,000.002%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 6170116712
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $203.00 | $125.86 | $30.00 | $95.86 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $151.00 | $93.62 | $0.00 | $93.62 | Paid |
| Totals | $354.00 | $219.48 | $30.00 | $189.48 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-582793
- 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-022295 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-04: CORE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 20 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) | 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-06-04 18:11
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$354.00
Plan discount
$134.52
contracted rate
Plan paid
$189.48
You may owe
$30.00
copay, deductible and coinsurance
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-2026-011764 | 2026-08-16 | Riverside Primary Care Associates | $379.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.