CLM-2026-025181
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-05-09 at office (POS 11). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Kimberly Parker
- Member ID
- none on golden record
- Date of birth
- 1947-03-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-411870
- Relationship
- Self
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1807692383
- Network
- In network
- Rendering NPI
- 9773794190
- Location
- Mesa, AZ · TIN 56-5443846
- Authorisation / referral
- none / REF209205
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 | $248.00 | $153.76 | — | — | PendedIDQ |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $373.00 | $231.26 | — | — | PendedIDQ |
| Totals | $621.00 | $385.02 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-935277
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000463; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 8 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 (1807692383). | |
| 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 Associates2026-05-09 18:29
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000463; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.