Professional claim · CMS-1500 · EDI 837P
CLM-2026-014069
Lakeside Endocrine Associates, Endocrinology. Service 2026-07-22 at office (POS 11). Received 2026-08-14.
ApprovedOut of network
Billed
$547.00
3 lines
Allowed
$246.15
contract rate applied
Plan pays
$216.90
approved
Member owes
$29.25
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Andy Andrews
- Member ID
- UHC-85810-85
- Date of birth
- 1997-02-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404093
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-4142
- Coverage period
- 2025-11-01 to present
- Deductible
- $2,228.38 of $2,500.0089%
- Out-of-pocket maximum
- $1,006.18 of $5,000.0020%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 9384863483
- Location
- Mesa, AZ · TIN 27-1877258
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $65.00 | $29.25 | $29.25 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $286.00 | $128.70 | $0.00 | $128.70 | Paid |
| 3 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1,2 | $196.00 | $88.20 | $0.00 | $88.20 | Paid |
| Totals | $547.00 | $246.15 | $29.25 | $216.90 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-132233
- 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-024626 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-22: N/A (PPO), effective 2025-11-01. | |
| 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 | 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 Endocrine Associates2026-07-22 09:59
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$547.00
Plan discount
$300.85
out-of-network allowance
Plan paid
$216.90
You may owe
$29.25
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.