CLM-2026-012728
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-02-24 at office (POS 11). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Paul Luna
- Member ID
- UHC-71549-96
- Date of birth
- 1974-05-11
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-425093
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,010.44 of $3,500.0057%
- Out-of-pocket maximum
- $1,404.00 of $7,000.0020%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 1728508759
- Location
- Denver, CO · TIN 22-9016721
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $342.00 | $212.04 | $25.00 | $187.04 | Paid |
| Totals | $342.00 | $212.04 | $25.00 | $187.04 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-228342
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017854 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-24: MEDICARE-ADV-B (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 10 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 (8566398227). | |
| 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 Associates2026-02-24 10:57
Patient seen for chronic kidney disease, stage 3 unspecified.
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001221 | 2026-07-20 | Pinecrest Medical Group | $2,639.00 | Needs review |
| CLM-2026-030800 | 2026-03-11 | Sunrise Heart Institute | $970.00 | Needs review |
| CLM-2026-030799 | 2026-03-11 | Meadow Heart Institute | $970.00 | 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.