CLM-2026-013361
Lakeside Medical Group, Family Medicine. Service 2026-04-04 at office (POS 11). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Ronald Watkins
- Member ID
- UHC-74277-24
- Date of birth
- 2008-06-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-410330
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4816
- Coverage period
- 2023-07-01 to present
- Deductible
- $758.77 of $2,500.0030%
- Out-of-pocket maximum
- $1,812.31 of $5,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6025022396
- Network
- In network
- Rendering NPI
- 6151107334
- Location
- Houston, TX · TIN 83-6077797
- 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 | — | 1 | 1 | $198.00 | $122.76 | $40.00 | $82.76 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $41.00 | $25.42 | $0.00 | $25.42 | Paid |
| Totals | $239.00 | $148.18 | $40.00 | $108.18 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-837915
- 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-011873 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-04: MEDICARE-ADV-A (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 29 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 (6025022396). | |
| 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 Group2026-04-04 12:48
Patient seen for low back pain, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-03 03:36
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-837915.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
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-2026-022247 | 2026-01-18 | Northgate Medical Group | $469.00 | 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
Authorisation must be confirmed with UM before payment.