CLM-2026-013899
Lakeside Medical Group, Family Medicine. Service 2026-06-05 at office (POS 11). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Olivia Cooper
- Member ID
- UHC-66987-31
- Date of birth
- 1981-09-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423093
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4230
- Coverage period
- 2022-05-01 to 2026-05-21
- Deductible
- $2,100.35 of $2,500.0084%
- Out-of-pocket maximum
- $2,757.72 of $7,500.0037%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 8137188297
- 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 | — | 1 | 1 | $250.00 | $155.00 | — | — | DeniedCO27 |
| Totals | $250.00 | $155.00 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-586962
- 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-002290 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-05 is after coverage terminated on 2026-05-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-06-05 15:55
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-06-28 02:26
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-28 13:08
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-05 is after coverage terminated on 2026-05-21.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.