CLM-2026-023976
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-08-11 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Billy Weber
- Member ID
- UHC-14482-44
- Date of birth
- 1989-01-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403699
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1233
- Coverage period
- 2023-08-01 to present
- Deductible
- $673.58 of $1,000.0067%
- Out-of-pocket maximum
- $1,959.07 of $4,000.0049%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6735813951
- Network
- In network
- Rendering NPI
- 9932008177
- Location
- Denver, CO · TIN 58-6102170
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $54.00 | $33.48 | $30.00 | $3.48 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1,2 | $80.00 | $49.60 | $0.00 | $49.60 | Paid |
| Totals | $134.00 | $83.08 | $30.00 | $53.08 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-100405
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003896 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-11: MEDICARE-ADV-A (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 44 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 (6735813951). | |
| 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 Associates2026-08-11 09:49
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.