CLM-2026-019800
Lakeside Medical Group, Family Medicine. Service 2026-05-19 at office (POS 11). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Mary Alvarado
- Member ID
- UHC-45054-41
- Date of birth
- 1938-10-26
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416453
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3282
- Coverage period
- 2025-09-01 to 2026-03-03
- Deductible
- $1,311.65 of $1,500.0087%
- Out-of-pocket maximum
- $1,430.06 of $3,000.0048%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4961481189
- Network
- Out of network
- Rendering NPI
- 5288040368
- 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 | 36415 | Venipuncture | — | 1 | 1 | $18.00 | $8.10 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $193.00 | $86.85 | — | — | DeniedCO27 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $251.00 | $112.95 | — | — | DeniedCO27 |
| Totals | $462.00 | $207.90 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-245298
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035201 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-19 is after coverage terminated on 2026-03-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 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 | 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-05-19 10:14
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-17 01:35
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-17 09:35
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-05-19 is after coverage terminated on 2026-03-03. 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
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.