CLM-2026-017829
Lakeside Medical Group, Family Medicine. Service 2026-04-12 at office (POS 11). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Aisha Holmes
- Member ID
- UHC-50329-53
- Date of birth
- 2002-05-07
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-401246
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1491
- Coverage period
- 2022-12-01 to present
- Deductible
- $813.46 of $2,500.0033%
- Out-of-pocket maximum
- $603.89 of $7,500.008%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4775513755
- Network
- In network
- Rendering NPI
- 5649255572
- Location
- Dallas, TX · TIN 51-2524013
- 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 | 90471 | Immunization administration | — | 1 | 1 | $32.00 | $19.84 | $19.84 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $208.00 | $128.96 | $0.00 | $128.96 | Paid |
| Totals | $240.00 | $148.80 | $19.84 | $128.96 | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-618893
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028881 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-04-12: - (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 36 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 | Pass | In-network provider Lakeside Medical Group (4775513755). | |
| 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 Group2026-04-12 09:29
Patient seen for acute upper respiratory infection, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-18 00:54
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-618893.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031535 | 2026-04-04 | Unity Internal Medicine Associates | $101.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.