CLM-2026-014125
Lakeside Endocrine Associates, Endocrinology. Service 2025-12-20 at office (POS 11). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Janet Wells
- Member ID
- UHC-54496-81
- Date of birth
- 1978-07-25
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-425934
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5202
- Coverage period
- 2024-01-01 to present
- Deductible
- $746.12 of $1,000.0075%
- Out-of-pocket maximum
- $724.59 of $3,000.0024%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 4914385289
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $359.00 | $161.55 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1 | $45.00 | $20.25 | — | — | Review |
| Totals | $404.00 | $181.80 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-708973
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005274 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-20: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 28 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 | Review | CO16 | Documentation incomplete: “Patient seen for hypothyroidism, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Endocrine Associates2025-12-20 10:21
Patient seen for hypothyroidism, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-17 05:09
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Patient seen for hypothyroidism, unspecified. Note dictated; signature pending.”.
- AI recommendationPended2026-10-23 19:14The claim is pended due to incomplete documentation. The clinical note indicates that the note is dictated but the signature is pending, and a development letter has been sent to the provider. The claim cannot be adjudicated until the missing signature is provided.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:14 · 727438cd
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010772 | 2026-08-18 | Unity Cardiovascular Associates | $374.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note indicates that the note is dictated but the signature is pending, and a development letter has been sent to the provider. The claim cannot be adjudicated until the missing signature is provided.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.