CLM-2026-026657
Lakeside Medical Group, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-06-13.
Member
Resolved through the identity graph
- Member
- Aisha Hernandez
- Member ID
- UHC-28782-95
- Date of birth
- 1983-11-18
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-408748
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2111
- Coverage period
- 2024-11-01 to 2026-02-22
- Deductible
- $871.52 of $1,500.0058%
- Out-of-pocket maximum
- $1,838.68 of $4,500.0041%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4775513755
- Network
- In network
- Rendering NPI
- 1750250718
- Location
- Dallas, TX · TIN 51-2524013
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $275.00 | $170.50 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $220.00 | $136.40 | — | — | DeniedCO27 |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $13.64 | — | — | DeniedCO27 |
| Totals | $517.00 | $320.54 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-877017
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013889 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-12 is after coverage terminated on 2026-02-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 Medical Group (4775513755). | |
| 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 Group2026-05-12 15:43
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-13 02:21
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-12 is after coverage terminated on 2026-02-22.
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
Service after coverage termination.