CLM-2026-021326
Lakeside Medical Group, Family Medicine. Service 2025-12-23 at office (POS 11). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Laura Hill
- Member ID
- UHC-22551-06
- Date of birth
- 1975-03-25
- Identity
- Verified2 records, confidence 0.87
- Claim record
- CLMCLM-428466
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3000
- Coverage period
- 2021-11-01 to present
- Deductible
- $547.10 of $1,500.0036%
- Out-of-pocket maximum
- $2,978.71 of $6,000.0050%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 1573414715
- Location
- San Diego, CA · TIN 83-7560587
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $211.00 | $130.82 | — | — | Review |
| Totals | $211.00 | $130.82 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-965812
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003322 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2025-12-23: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-021325; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Medical Group (3911891331). | |
| 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 Group2025-12-23 11:55
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-15 02:02
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-021325.pdf1 page
Provider cover letter requesting replacement of CLM-2026-021325.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-021325; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021325 | 2025-12-23 | Lakeside Medical Group | $211.00 | Approved |
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
Replacement claim supersedes the original.