CLM-2026-031753
Lakeside Endocrine Associates, Endocrinology. Service 2026-07-19 at office (POS 11). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Christian Hayes
- Member ID
- UHC-86167-37
- Date of birth
- 1963-03-14
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-421267
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2288
- Coverage period
- 2022-06-01 to present
- Deductible
- $341.69 of $500.0068%
- Out-of-pocket maximum
- $867.82 of $2,000.0043%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 5648838790
- Network
- Out of network
- Rendering NPI
- 5639499206
- Location
- Mesa, AZ · TIN 27-1877258
- Authorisation / referral
- none / REF310250
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 | $261.00 | $117.45 | — | — | DeniedCO204 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $35.00 | $15.75 | — | — | DeniedCO204 |
| Totals | $296.00 | $133.20 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-102460
- 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-006805 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-19: NAVIGATE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 7 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 | Fail | CO204 | Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Endocrine Associates2026-07-19 13:35
Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-26 06:02
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5648838790 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002433 | 2026-07-30 | Northgate Medical Group | $275.00 | Approved |
| CLM-2026-008082 | 2026-03-21 | Evergreen Clinical Laboratories | $197.00 | Approved |
| CLM-2026-028200 | 2026-01-18 | Sunrise Medical Group | $163.00 | Denied |
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
No out-of-network benefit on this plan.