CLM-2026-018926
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-08-21 at office (POS 11). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Kenneth Riley
- Member ID
- UHC-28168-17
- Date of birth
- 1956-05-05
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-412104
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8911
- Coverage period
- 2023-02-01 to present
- Deductible
- $123.45 of $500.0025%
- Out-of-pocket maximum
- $712.76 of $2,000.0036%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 5187613224
- Location
- Los Angeles, CA · TIN 18-5876521
- 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 | $291.00 | $180.42 | $30.00 | $150.42 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1,2 | $72.00 | $44.64 | $0.00 | $44.64 | Paid |
| Totals | $363.00 | $225.06 | $30.00 | $195.06 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-870172
- 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-012998 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-21: OPTIONS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 14 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 Internal Medicine Associates (6644545769). | |
| 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 Internal Medicine Associates2026-08-21 13:42
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
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
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
Clean claim, priced at contract rate.