Professional claim · CMS-1500 · EDI 837P
CLM-2026-014024
Lakeside Medical Group, Family Medicine. Service 2025-12-20 at office (POS 11). Received 2026-01-09.
Approved
Billed
$611.00
2 lines
Allowed
$378.82
contract rate applied
Plan pays
$348.82
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Virginia Gibson
- Member ID
- UHC-43822-84
- Date of birth
- 1959-11-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400469
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-2983
- Coverage period
- 2022-11-01 to present
- Deductible
- $201.78 of $500.0040%
- Out-of-pocket maximum
- $375.25 of $2,000.0019%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6025022396
- Network
- In network
- Rendering NPI
- 2288563184
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $296.00 | $183.52 | $30.00 | $153.52 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $315.00 | $195.30 | $0.00 | $195.30 | Paid |
| Totals | $611.00 | $378.82 | $30.00 | $348.82 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-549163
- 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-002860 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-20: - (PPO), effective 2022-11-01. | |
| 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 (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. |
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 Group2025-12-20 18:32
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$611.00
Plan discount
$232.18
contracted rate
Plan paid
$348.82
You may owe
$30.00
copay, deductible and coinsurance
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-2026-025843 | 2025-09-23 | Canyon Primary Care Associates | $229.00 | Denied |
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.