CLM-2026-023395
Lakeside Medical Group, Family Medicine. Service 2026-01-18 at office (POS 11). Received 2026-04-29.
Member
Resolved through the identity graph
- Member
- Christine Ray
- Member ID
- UHC-79756-16
- Date of birth
- 2001-09-20
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-413413
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-6548
- Coverage period
- 2024-11-01 to present
- Deductible
- $11.85 of $2,500.000%
- Out-of-pocket maximum
- $1,367.55 of $5,000.0027%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3911891331
- Network
- In network
- Rendering NPI
- 6147947264
- 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 | $232.00 | $143.84 | — | — | DeniedCO29 |
| Totals | $232.00 | $143.84 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-764668
- 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-006016 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-18: - (PPO), effective 2024-11-01. | |
| Timely filing | Fail | CO29 | Received 101 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 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 Group2026-01-18 18:30
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-04-29 02:26
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)2026-04-29 09:22
Reviewed with the member's history on file. Holding for the items listed above.
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 101 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.