CLM-2026-024154
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-04-03 at office (POS 11). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Vicky Lynch
- Member ID
- UHC-39117-66
- Date of birth
- 1995-10-10
- Identity
- Verified4 records, confidence 0.87
- Claim record
- CLMCLM-400380
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1551
- Coverage period
- 2025-05-01 to present
- Deductible
- $266.45 of $1,000.0027%
- Out-of-pocket maximum
- $120.62 of $2,000.006%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 6344860401
- Location
- Los Angeles, CA · TIN 18-5876521
- 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 | $55.00 | $34.10 | $20.00 | $14.10 | Paid |
| Totals | $55.00 | $34.10 | $20.00 | $14.10 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-315624
- 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-030704 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-04-03: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 41 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 (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 Associates2026-04-03 09:59
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-14 03:18
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-315624.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015737 | 2026-09-11 | Pinecrest Medical Group | $393.00 | Approved |
| CLM-2026-028596 | 2026-09-08 | Lakeside Bone and Joint Center | $251.00 | 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
Authorisation must be confirmed with UM before payment.