CLM-2026-021642
Lakeside Internal Medicine Associates, Internal Medicine. Service 2025-09-06 at office (POS 11). Received 2026-02-27.
Member
Resolved through the identity graph
- Member
- Janice Kelly
- Member ID
- UHC-98691-32
- Date of birth
- 1956-11-05
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-423915
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2264
- Coverage period
- 2023-10-01 to present
- Deductible
- $310.17 of $1,000.0031%
- Out-of-pocket maximum
- $193.45 of $2,000.0010%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1807692383
- Network
- In network
- Rendering NPI
- 2496796261
- Location
- Mesa, AZ · TIN 56-5443846
- 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 | $273.00 | $169.26 | — | — | DeniedCO29 |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1 | $65.00 | $40.30 | — | — | DeniedCO29 |
| Totals | $338.00 | $209.56 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-699775
- 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-016341 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-09-06: SELECT-EPO (EPO), effective 2023-10-01. | |
| Timely filing | Fail | CO29 | Received 174 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Internal Medicine Associates (1807692383). | |
| 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 Internal Medicine Associates2025-09-06 18:28
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-02-27 00:07
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-27 10:52
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 174 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022589 | 2026-08-23 | Harbor Diabetes Center | $180.00 | Approved |
| CLM-2026-019845 | 2026-02-13 | Mesa Physical Therapy | $276.00 | Needs review |
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
Received after the timely-filing limit.