Claims workbench/CLM-2026-028769
Professional claim · CMS-1500 · EDI 837P

CLM-2026-028769

Lakeside Medical Group, Family Medicine. Service 2026-07-03 at office (POS 11). Received 2026-07-19.

Approved
Billed
$264.00
1 line
Allowed
$163.68
contract rate applied
Plan pays
$133.68
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Gerald Gardner
Member ID
UHC-17504-13
Date of birth
1952-06-01
Identity
Verified3 records, confidence 0.94
Claim record
CLMCLM-420308
Relationship
Self, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-2965
Coverage period
2022-07-01 to present
Deductible
$81.10 of $2,500.003%
Out-of-pocket maximum
$2,580.88 of $7,500.0034%
Copays
office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits
0 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
3911891331
Network
In network
Rendering NPI
9044026588
Location
San Diego, CA · TIN 83-7560587
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$264.00$163.68$30.00$133.68Paid
Totals$264.00$163.68$30.00$133.68
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-964720
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

CheckResultCodeDetail
Member identityPassAttached to MBR-036894 (verified, link confidence 0.94).
EligibilityPassActive on 2026-07-03: CORE-HMO (HMO), effective 2022-07-01.
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Lakeside Medical Group (3911891331).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Lakeside Medical Group2026-07-03 13:04

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$264.00
Plan discount
$100.32
contracted rate
Plan paid
$133.68
You may owe
$30.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity