CLM-2026-024146
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-03-29 at office (POS 11). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Mason Munoz
- Member ID
- UHC-98890-36
- Date of birth
- 2007-02-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-409408
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5566
- Coverage period
- 2022-04-01 to present
- Deductible
- $792.63 of $1,500.0053%
- Out-of-pocket maximum
- $1,052.60 of $3,000.0035%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6735813951
- Network
- In network
- Rendering NPI
- 8603235275
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $402.00 | $249.24 | $20.00 | $229.24 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1 | $60.00 | $37.20 | $0.00 | $37.20 | Paid |
| Totals | $462.00 | $286.44 | $20.00 | $266.44 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-560062
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018332 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-29: OPTIONS-PPO (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 12 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 Associates2026-03-29 13:11
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032405 | 2026-03-05 | Heritage GI Associates | $4,792.00 | Approved |
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.