CLM-2026-025956
Lakeside Medical Group, Internal Medicine. Service 2026-02-06 at office (POS 11). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Samantha Anderson
- Member ID
- none on golden record
- Date of birth
- 1971-12-10
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-418538
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group UNKNOWN
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,392.64 of $2,500.0056%
- Out-of-pocket maximum
- $1,024.26 of $5,000.0020%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 2143231852
- Network
- In network
- Rendering NPI
- 4334509450
- Location
- Houston, TX · TIN 29-4552150
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $71.00 | $44.02 | — | — | DeniedCO18 |
| Totals | $71.00 | $44.02 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-672291
- 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 | Pass | Attached to MBR-021496 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-02-06: MEDICARE-ADV-A (MA), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 63 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-025955: 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 Medical Group (2143231852). | |
| 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 Medical Group2026-02-06 10:07
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-04-10 01:48
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 engineDenied2026-10-22 12:44Eligibility: Active on 2026-02-06: MEDICARE-ADV-A (MA), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Exact duplicate of CLM-2026-025955: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025955 | 2026-02-06 | Lakeside Medical Group | $71.00 | Approved |
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.