CLM-2026-022523
Lakeside Medical Group, Internal Medicine. Service 2025-12-17 at office (POS 11). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Jennifer Price
- Member ID
- UHC-20738-60
- Date of birth
- 1965-04-26
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-427598
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3554
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,224.37 of $3,500.0064%
- Out-of-pocket maximum
- $2,275.31 of $7,000.0033%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 2143231852
- Network
- In network
- Rendering NPI
- 9277672462
- Location
- Houston, TX · TIN 29-4552150
- 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 | $116.00 | $71.92 | $30.00 | $41.92 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $86.00 | $53.32 | $0.00 | $53.32 | Paid |
| Totals | $202.00 | $125.24 | $30.00 | $95.24 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-775957
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003233 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-17: OPTIONS-PPO (PPO), effective 2022-05-01. | |
| 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 Medical Group (2143231852). | |
| 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 Group2025-12-17 15:02
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023153 | 2026-07-02 | Riverside Primary Care Associates | $279.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.