Claims workbench/CLM-2026-016413

Professional claim · CMS-1500 · EDI 837P

CLM-2026-016413

Lakeside Medical Group, Family Medicine. Service 2026-08-05 at office (POS 11). Received 2026-10-04.

DeniedOut of network

Billed

$451.00

3 lines

Allowed

$202.95

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Theresa Hoffman
Member ID: UHC-15893-12
Date of birth: 1982-08-08
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-405364
Relationship: Child, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-2584
Coverage period: 2024-04-01 to present
Deductible: $730.21 of $1,000.0073%
Out-of-pocket maximum: $640.69 of $2,000.0032%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 13 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 4961481189
Network: Out of network
Rendering NPI: 9879063557
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	99203	Office visit, new patient, low complexity	—	1	1	$222.00	$99.90	—	—	DeniedCO18
2	36415	Venipuncture	—	1	1	$21.00	$9.45	—	—	DeniedCO18
3	99214	Office visit, established patient, moderate complexity	—	1	2	$208.00	$93.60	—	—	DeniedCO18
Totals						$451.00	$202.95	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal

Claim header

Patient account: PA-160040
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-031791 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-05: OPTIONS-PPO (PPO), effective 2024-04-01.
Timely filing	Pass		Received 60 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-016412: same member, date of service, procedures and billing provider. Exact duplicate claim or service
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Medical Group2026-08-05 18:54
Patient seen for acute upper respiratory infection, unspecified.
SystemSystem: Claims system2026-10-04 05:16
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-04 12:02
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-016412: same member, date of service, procedures and billing provider. Provider 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-2026-016412	2026-08-05	Lakeside Medical Group	$451.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity