CLM-2026-021117
Lakeside Endocrine Associates, Endocrinology. Service 2026-02-05 at office (POS 11). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Diego Payne
- Member ID
- UHC-65200-03
- Date of birth
- 1962-04-18
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-400400
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3894
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,429.57 of $3,500.0041%
- Out-of-pocket maximum
- $2,526.02 of $7,000.0036%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- 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
- 7506701227
- Location
- Mesa, AZ · TIN 27-1877258
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $79.00 | $35.55 | $35.55 | $0.00 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $307.00 | $138.15 | $0.00 | $138.15 | Paid |
| Totals | $386.00 | $173.70 | $35.55 | $138.15 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-280040
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001483 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-05: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 4 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 Endocrine Associates2026-02-05 11:51
Patient seen for type 2 diabetes mellitus without complications.
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 engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011437 | 2026-06-21 | Valley Imaging Center | $3,457.00 | Denied |
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.