Professional claim · CMS-1500 · EDI 837P
CLM-2026-033174
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-05-07 at office (POS 11). Received 2026-06-20.
Approved
Billed
$539.00
2 lines
Allowed
$334.18
contract rate applied
Plan pays
$294.18
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Bruce Burke
- Member ID
- UHC-27034-47
- Date of birth
- 1979-08-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-424561
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group NULL
- Coverage period
- 2021-11-01 to present
- Deductible
- $671.32 of $1,000.0067%
- Out-of-pocket maximum
- $770.48 of $4,000.0019%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1807692383
- Network
- In network
- Rendering NPI
- 6970811710
- Location
- Mesa, AZ · TIN 56-5443846
- Authorisation / referral
- none / REF984657
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 | $240.00 | $148.80 | $40.00 | $108.80 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $299.00 | $185.38 | $0.00 | $185.38 | Paid |
| Totals | $539.00 | $334.18 | $40.00 | $294.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
Claim header
- Patient account
- PA-523687
- 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-001446 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-07: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 44 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 (1807692383). | |
| 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Internal Medicine Associates2026-05-07 13:07
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$539.00
Plan discount
$204.82
contracted rate
Plan paid
$294.18
You may owe
$40.00
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026264 | 2026-06-10 | Mesa Family Practice | $35.00 | Approved |
| CLM-2026-015553 | 2026-05-23 | Summit Community Hospital | $3,540.00 | Approved |
| CLM-2026-024282 | 2026-02-17 | Northgate Clinical Laboratories | $167.00 | Denied |
| CLM-2026-024281 | 2026-02-17 | Northgate Clinical Laboratories | $167.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
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.