CLM-2026-024080
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-08-24 at office (POS 11). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Theresa Ferguson
- Member ID
- UHC-72869-72
- Date of birth
- 1971-08-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409394
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1831
- Coverage period
- 2023-12-01 to present
- Deductible
- $195.53 of $2,500.008%
- Out-of-pocket maximum
- $4,124.80 of $10,000.0041%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 2852129545
- Location
- Los Angeles, CA · TIN 18-5876521
- Authorisation / referral
- none / REF440942
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $204.00 | $126.48 | — | — | DeniedCO18 |
| Totals | $204.00 | $126.48 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-922544
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014146 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-24: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024079: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Internal Medicine Associates (6644545769). | |
| 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 Associates2026-08-24 10:17
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-10-08 00:32
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-024079: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024079 | 2026-08-24 | Lakeside Internal Medicine Associates | $204.00 | Approved |
| CLM-2026-007999 | 2026-08-30 | Heritage Family Practice | $53.00 | Needs review |
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
Exact duplicate of an earlier submission.