CLM-2026-026342
Lakeside Endocrine Associates, Endocrinology. Service 2026-06-01 at office (POS 11). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Debra Murphy
- Member ID
- UHC-04747-38
- Date of birth
- 1955-02-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412257
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9539
- Coverage period
- 2023-06-01 to present
- Deductible
- $386.24 of $3,500.0011%
- Out-of-pocket maximum
- $2,750.72 of $14,000.0020%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 8095272240
- Location
- Mesa, AZ · TIN 27-1877258
- Authorisation / referral
- none / REF143976
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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $201.00 | $90.45 | — | — | DeniedCO204 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $64.00 | $28.80 | — | — | DeniedCO204 |
| Totals | $265.00 | $119.25 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-552453
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033931 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-01: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 6 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 | Fail | CO204 | Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Endocrine Associates2026-06-01 14:14
Follow-up for hypothyroidism, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-07 00:24
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-07 11:31
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.