CLM-2026-021603
Lakeside Endocrine Associates, Endocrinology. Service 2026-01-20 at office (POS 11). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Abigail George
- Member ID
- UHC-26434-29
- Date of birth
- 1949-07-17
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-405020
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5219
- Coverage period
- 2025-10-01 to present
- Deductible
- $677.01 of $1,000.0068%
- Out-of-pocket maximum
- $399.44 of $2,000.0020%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 9339556539
- Location
- Mesa, AZ · TIN 27-1877258
- Authorisation / referral
- none / REF423575
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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $170.00 | $76.50 | — | — | DeniedCO204 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $229.00 | $103.05 | — | — | DeniedCO204 |
| Totals | $399.00 | $179.55 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-919978
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007370 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-20: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| 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 | 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 Associates2026-01-20 10:04
Follow-up for thyrotoxicosis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-24 05:55
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider 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-2026-017699 | 2026-06-13 | Lakeside Clinical Laboratories | $102.00 | Approved |
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
No out-of-network benefit on this plan.