Professional claim · CMS-1500 · EDI 837P
CLM-2026-013081
Lakeside Medical Group, Family Medicine. Service 2026-02-15 at office (POS 11). Received 2026-02-18.
ApprovedOut of network
Billed
$260.00
2 lines
Allowed
$117.00
contract rate applied
Plan pays
$92.00
approved
Member owes
$25.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Kevin Ortega
- Member ID
- UHC-38146-61
- Date of birth
- 1950-11-09
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-425957
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-8150
- Coverage period
- 2024-02-01 to present
- Deductible
- $98.57 of $500.0020%
- Out-of-pocket maximum
- $63.38 of $2,000.003%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3004199154
- Network
- Out of network
- Rendering NPI
- 7691566328
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $238.00 | $107.10 | $25.00 | $82.10 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $22.00 | $9.90 | $0.00 | $9.90 | Paid |
| Totals | $260.00 | $117.00 | $25.00 | $92.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-714030
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008767 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-15: UNKNOWN (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 3 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-02-15 13:45
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$260.00
Plan discount
$143.00
out-of-network allowance
Plan paid
$92.00
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
No other claims.
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.