CLM-2026-030916
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-06-12 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Karen Walker
- Member ID
- UHC-57736-99
- Date of birth
- 1965-08-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-404720
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4733
- Coverage period
- 2025-07-01 to present
- Deductible
- $655.55 of $3,500.0019%
- Out-of-pocket maximum
- $2,682.99 of $14,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 6934828255
- Location
- Denver, CO · TIN 22-9016721
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $92.00 | $57.04 | $25.00 | $32.04 | Paid |
| Totals | $92.00 | $57.04 | $25.00 | $32.04 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-986896
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009878 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-12: MEDICARE-ADV-B (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 21 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 (8566398227). | |
| 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 Associates2026-06-12 17:59
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.