CLM-2026-021227
Lakeside Digestive Health Center, Gastroenterology. Service 2026-07-21 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Bruce Porter
- Member ID
- none on golden record
- Date of birth
- 1986-12-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428179
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-8939
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,087.40 of $3,500.0031%
- Out-of-pocket maximum
- $276.47 of $14,000.002%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 4719697615
- Location
- Denver, CO · TIN 37-4223782
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $287.00 | $177.94 | — | — | PendedIDQ |
| Totals | $287.00 | $177.94 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-142262
- 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 | Fail | IDQ | Member record is in open steward case CASE-001674; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-21: MEDICARE-ADV-A (MA), effective 2023-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 25 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 Digestive Health Center (5154884873). | |
| 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 Digestive Health Center2026-07-21 17:00
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001674; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-21: MEDICARE-ADV-A (MA), effective 2023-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.