Professional claim · CMS-1500 · Paper
CLM-2026-028799
Lakeside Medical Group, Family Medicine. Service 2026-08-29 at office (POS 11). Received 2026-09-29.
Denied
Billed
$424.00
2 lines
Allowed
$262.88
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Diana Woods
- Member ID
- UHC-77073-62
- Date of birth
- 1989-12-02
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-409558
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3346
- Coverage period
- 2024-04-01 to 2026-05-03
- Deductible
- $77.43 of $1,000.008%
- Out-of-pocket maximum
- $466.34 of $3,000.0016%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6025022396
- Network
- In network
- Rendering NPI
- 5206071545
- Location
- Houston, TX · TIN 83-6077797
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $230.00 | $142.60 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $194.00 | $120.28 | — | — | DeniedCO27 |
| Totals | $424.00 | $262.88 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
- Patient account
- PA-600952
- 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-005852 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-29 is after coverage terminated on 2026-05-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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 (6025022396). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-08-29 14:23
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-09-29 06:45
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-29 is after coverage terminated on 2026-05-03.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026876 | 2026-02-21 | Pinecrest Primary Care Associates | $25.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.