CLM-2026-026336
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-04-15 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Virginia Carr
- Member ID
- UHC-61614-40
- Date of birth
- 1959-09-19
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-406868
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3616
- Coverage period
- 2024-05-01 to present
- Deductible
- $437.33 of $1,000.0044%
- Out-of-pocket maximum
- $773.06 of $2,000.0039%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5141407317
- Network
- In network
- Rendering NPI
- 4346573940
- Location
- Charlotte, NC · TIN 14-0698276
- 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 | $418.00 | $259.16 | $20.00 | $239.16 | Paid |
| Totals | $418.00 | $259.16 | $20.00 | $239.16 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-288016
- 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-012558 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 38 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 (5141407317). | |
| 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 Associates2026-04-15 15:05
Patient seen for chronic kidney disease, stage 3 unspecified.
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-2026-030325 | 2026-05-05 | Evergreen Primary Care Associates | $252.00 | Approved |
| CLM-2026-031841 | 2026-03-20 | Mesa Medical Group | $541.00 | Approved |
| CLM-2026-001464 | 2025-12-31 | Unity Family Practice | $204.00 | Needs review |
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.