CLM-2026-025721
Lakeside Medical Group, Family Medicine. Service 2026-09-15 at office (POS 11). Received 2026-10-01.
Member
Resolved through the identity graph
- Member
- Philip Simmons
- Member ID
- UHC-94170-33
- Date of birth
- 1967-10-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421488
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2425
- Coverage period
- 2024-10-01 to present
- Deductible
- $1,140.90 of $2,500.0046%
- Out-of-pocket maximum
- $2,776.32 of $7,500.0037%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3004199154
- Network
- Out of network
- Rendering NPI
- 3271876427
- Location
- Atlanta, GA · TIN 59-2183874
- 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 | 36415 | Venipuncture | — | 1 | 1 | $16.00 | $7.20 | — | — | Review |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $239.00 | $107.55 | — | — | Review |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $13.95 | — | — | Review |
| Totals | $286.00 | $128.70 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-673912
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038877 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-15: CHOICE-PLUS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 16 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vital”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-09-15 10:43
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-01 04:51
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vital”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005850 | 2026-07-05 | Lakeside Endocrine Associates | $122.00 | Approved |
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
Development letter outstanding.