CLM-2026-019145
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-08-09 at office (POS 11). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Mariana Nelson
- Member ID
- UHC-30205-72
- Date of birth
- 1967-03-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-430124
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0283
- Coverage period
- 2025-03-01 to 2026-06-10
- Deductible
- $1,208.34 of $1,500.0081%
- Out-of-pocket maximum
- $323.37 of $4,500.007%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 1125556245
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $102.00 | $63.24 | — | — | DeniedCO27 |
| Totals | $102.00 | $63.24 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-561755
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009489 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-09 is after coverage terminated on 2026-06-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 Associates2026-08-09 10:09
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-09-13 01:14
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-13 16:46
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-09 is after coverage terminated on 2026-06-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034328 | 2026-01-14 | Riverside Imaging Center | $468.00 | 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
Service after coverage termination.