CLM-2026-015930
Lakeside Medical Group, Internal Medicine. Service 2025-11-30 at office (POS 11). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Judith Lopez
- Member ID
- UHC-84948-25
- Date of birth
- 2002-05-16
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-405083
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1165
- Coverage period
- 2021-01-01 to present
- Deductible
- $204.67 of $1,000.0020%
- Out-of-pocket maximum
- $850.34 of $3,000.0028%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 8469211147
- Location
- Tampa, FL · TIN 85-1984822
- 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 | $313.00 | $194.06 | — | — | DeniedCO18 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $115.00 | $71.30 | — | — | DeniedCO18 |
| Totals | $428.00 | $265.36 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-862962
- 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-003221 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-30: N/A (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 59 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-015929: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Medical Group (3228212296). | |
| 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 Group2025-11-30 09:39
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-28 01:38
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-015929: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009621 | 2026-05-19 | Heritage Family Practice | $214.00 | Approved |
| CLM-2026-002149 | 2026-05-10 | Evergreen Rehabilitation Center | $186.00 | Approved |
| CLM-2026-015929 | 2025-11-30 | Lakeside Medical Group | $428.00 | Approved |
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
Exact duplicate of an earlier submission.