Professional claim · CMS-1500 · EDI 837P
CLM-2026-023584
Lakeside Medical Group, Family Medicine. Service 2026-04-05 at office (POS 11). Received 2026-04-26.
ApprovedOut of network
Billed
$493.00
2 lines
Allowed
$221.85
contract rate applied
Plan pays
$196.85
approved
Member owes
$25.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Teresa Burton
- Member ID
- UHC-61347-45
- Date of birth
- 1956-04-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423732
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8814
- Coverage period
- 2021-04-01 to present
- Deductible
- $108.27 of $500.0022%
- Out-of-pocket maximum
- $350.32 of $2,000.0018%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3004199154
- Network
- Out of network
- Rendering NPI
- 8201224465
- Location
- Atlanta, GA · TIN 59-2183874
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $280.00 | $126.00 | $25.00 | $101.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $213.00 | $95.85 | $0.00 | $95.85 | Paid |
| Totals | $493.00 | $221.85 | $25.00 | $196.85 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-547715
- 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-024048 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-05: MEDICARE-ADV-B (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 21 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-04-05 18:27
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$493.00
Plan discount
$271.15
out-of-network allowance
Plan paid
$196.85
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025581 | 2026-06-20 | Mesa Orthopedic Specialists | $244.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.