CLM-2026-022782
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-03-10 at office (POS 11). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Keith Munoz
- Member ID
- UHC-81023-71
- Date of birth
- 1963-11-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419667
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group N/A
- Coverage period
- 2024-02-01 to present
- Deductible
- $390.27 of $500.0078%
- Out-of-pocket maximum
- $712.12 of $1,500.0047%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1807692383
- Network
- In network
- Rendering NPI
- 7653906611
- Location
- Mesa, AZ · TIN 56-5443846
- Authorisation / referral
- none / REF981340
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 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1 | $67.00 | $41.54 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $251.00 | $155.62 | — | — | Review |
| Totals | $318.00 | $197.16 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-114168
- 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-026513 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: CORE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 39 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 Internal Medicine Associates (1807692383). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2026-03-10 15:15
Patient seen for unspecified atrial fibrillation. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-04-18 03:04
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-114168.pdf17 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Modifier 59 supported: distinct anatomical site documented.