CLM-2026-033115
Lakeside Medical Group, Family Medicine. Service 2026-03-08 at office (POS 11). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Luis Cole
- Member ID
- UHC-54865-68
- Date of birth
- 1976-05-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-424973
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1594
- Coverage period
- 2022-11-01 to present
- Deductible
- $781.49 of $2,500.0031%
- Out-of-pocket maximum
- $1,212.36 of $5,000.0024%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4775513755
- Network
- In network
- Rendering NPI
- 8158341809
- Location
- Dallas, TX · TIN 51-2524013
- 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 | $185.00 | $114.70 | — | — | Review |
| 2 | 36415 | Venipuncture | 25 | 1 | 1 | $18.00 | $11.16 | — | — | Review |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $308.00 | $190.96 | — | — | Review |
| Totals | $511.00 | $316.82 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-564036
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024255 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-08: CHOICE-PLUS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-033114; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Medical Group (4775513755). | |
| 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 Medical Group2026-03-08 09:03
Patient seen for encounter for general adult medical examination without abnormal findings. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-04-19 03:37
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-19 10:07
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-033114.pdf1 page
Provider cover letter requesting replacement of CLM-2026-033114.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-033114; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001027 | 2026-04-05 | Harbor Primary Care Associates | $50.00 | Approved |
| CLM-2026-033114 | 2026-03-08 | Lakeside Medical Group | $511.00 | Approved |
| CLM-2026-019505 | 2026-02-25 | Sunrise Physical Therapy | $124.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.