CLM-2026-019974
Lakeside Endocrine Associates, Endocrinology. Service 2026-08-10 at office (POS 11). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Anna Bowman
- Member ID
- UHC-89187-82
- Date of birth
- 2007-03-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428779
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0406
- Coverage period
- 2025-07-01 to 2026-01-08
- Deductible
- $512.24 of $1,500.0034%
- Out-of-pocket maximum
- $1,680.02 of $6,000.0028%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 8834685785
- Location
- Mesa, AZ · TIN 27-1877258
- Authorisation / referral
- none / REF169588
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $288.00 | $129.60 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $331.00 | $148.95 | — | — | DeniedCO27 |
| Totals | $619.00 | $278.55 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-933402
- 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-030140 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-10 is after coverage terminated on 2026-01-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 | Fail | CO204 | Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Endocrine Associates2026-08-10 15:28
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-21 00:51
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-10 is after coverage terminated on 2026-01-08. Provider network: Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018511 | 2026-07-22 | Meadow Imaging Center | $1,665.00 | Denied |
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.