Professional claim · CMS-1500 · Provider portal
CLM-2026-015798
Lakeside Medical Group, Family Medicine. Service 2026-02-23 at office (POS 11). Received 2026-03-26.
ApprovedOut of network
Billed
$594.00
3 lines
Allowed
$267.30
contract rate applied
Plan pays
$247.30
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Walter Carlson
- Member ID
- UHC-39159-19
- Date of birth
- 1955-10-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-428869
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9668
- Coverage period
- 2022-01-01 to present
- Deductible
- $132.80 of $500.0027%
- Out-of-pocket maximum
- $479.10 of $1,000.0048%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4961481189
- Network
- Out of network
- Rendering NPI
- 9514933941
- Location
- Mesa, AZ · TIN 54-1409504
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $243.00 | $109.35 | $20.00 | $89.35 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $205.00 | $92.25 | $0.00 | $92.25 | Paid |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $146.00 | $65.70 | $0.00 | $65.70 | Paid |
| Totals | $594.00 | $267.30 | $20.00 | $247.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-949931
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022203 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-23: MEDICARE-ADV-A (MA), effective 2022-01-01. | |
| Timely filing | Pass | Received 31 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-02-23 11:41
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$594.00
Plan discount
$326.70
out-of-network allowance
Plan paid
$247.30
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020990 | 2026-08-15 | Sunrise Family Practice | $531.00 | Approved |
| CLM-2026-013012 | 2026-07-26 | Northgate Reference Lab | $121.00 | Approved |
| CLM-2026-012817 | 2026-05-12 | Riverside Orthopedic Specialists | $28,906.00 | Needs review |
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.