Professional claim · CMS-1500 · EDI 837P
CLM-2026-031481
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-04-17 at office (POS 11). Received 2026-05-29.
Billed
$80.00
1 line
Allowed
$49.60
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Emma Ortiz
- Member ID
- UHC-56096-77
- Date of birth
- 1944-08-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-409975
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-4783
- Coverage period
- 2025-01-01 to present
- Deductible
- $949.78 of $2,500.0038%
- Out-of-pocket maximum
- $1,274.68 of $7,500.0017%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6644545769
- Network
- In network
- Rendering NPI
- 9845843546
- Location
- Los Angeles, CA · TIN 18-5876521
- 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 | $80.00 | $49.60 | — | — | PendedIDQ |
| Totals | $80.00 | $49.60 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-952210
- 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 | Fail | IDQ | Member record is in open steward case CASE-003080; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-17: N/A (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 42 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 (6644545769). | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Internal Medicine Associates2026-04-17 11:46
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003080; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.