CLM-2026-031863
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-06-13 at office (POS 11). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Donald Vazquez
- Member ID
- UHC-40919-31
- Date of birth
- 1960-05-26
- Identity
- Verified4 records, confidence 0.92
- Claim record
- CLMCLM-409588
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2910
- Coverage period
- 2022-09-01 to present
- Deductible
- $77.33 of $500.0015%
- Out-of-pocket maximum
- $447.05 of $2,000.0022%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5141407317
- Network
- In network
- Rendering NPI
- 7727751886
- Location
- Charlotte, NC · TIN 14-0698276
- Authorisation / referral
- none / REF216726
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $335.00 | $207.70 | — | — | DeniedCO18 |
| Totals | $335.00 | $207.70 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-215489
- 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-017076 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2026-06-13: NAVIGATE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031862: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Internal Medicine Associates (5141407317). | |
| 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 Associates2026-06-13 18:45
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-03 06:02
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-031862: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031862 | 2026-06-13 | Lakeside Internal Medicine Associates | $335.00 | Approved |
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
Exact duplicate of an earlier submission.