Professional claim · CMS-1500 · Provider portal
CLM-2026-021217
Lakeside Medical Group, Internal Medicine. Service 2026-07-24 at office (POS 11). Received 2026-08-10.
Approved
Billed
$70.00
1 line
Allowed
$43.40
contract rate applied
Plan pays
$13.40
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Lauren Guzman
- Member ID
- UHC-74677-14
- Date of birth
- 1969-10-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402289
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9484
- Coverage period
- 2023-05-01 to present
- Deductible
- $1,023.09 of $3,500.0029%
- Out-of-pocket maximum
- $418.95 of $7,000.006%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3228212296
- Network
- In network
- Rendering NPI
- 1732950542
- Location
- Tampa, FL · TIN 85-1984822
- 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 | $70.00 | $43.40 | $30.00 | $13.40 | Paid |
| Totals | $70.00 | $43.40 | $30.00 | $13.40 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
Claim header
- Patient account
- PA-834371
- 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-000956 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-24: MEDICARE-ADV-B (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 17 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 Medical Group (3228212296). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-07-24 12:49
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$70.00
Plan discount
$26.60
contracted rate
Plan paid
$13.40
You may owe
$30.00
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021218 | 2026-07-24 | Lakeside Medical Group | $70.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.