Professional claim · CMS-1500 · EDI 837P
CLM-2026-033222
Lakeside Internal Medicine Associates, Internal Medicine. Service 2026-02-05 at office (POS 11). Received 2026-03-04.
Approved
Billed
$339.00
2 lines
Allowed
$210.18
contract rate applied
Plan pays
$185.18
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Yuki Boyd
- Member ID
- UHC-23434-82
- Date of birth
- 1947-07-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418961
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5005
- Coverage period
- 2024-09-01 to present
- Deductible
- $172.21 of $1,000.0017%
- Out-of-pocket maximum
- $543.72 of $3,000.0018%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5141407317
- Network
- In network
- Rendering NPI
- 4613753845
- Location
- Charlotte, NC · TIN 14-0698276
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $267.00 | $165.54 | $25.00 | $140.54 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $72.00 | $44.64 | $0.00 | $44.64 | Paid |
| Totals | $339.00 | $210.18 | $25.00 | $185.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-871591
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017319 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-05: MEDICARE-ADV-B (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 27 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 (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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Internal Medicine Associates2026-02-05 09:55
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$339.00
Plan discount
$128.82
contracted rate
Plan paid
$185.18
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004194 | 2026-08-07 | Sunrise Clinical Laboratories | $104.00 | Approved |
| CLM-2026-012658 | 2026-04-11 | Riverside Regional Medical Center | $2,675.00 | Denied |
| CLM-2026-012657 | 2026-04-11 | Riverside Regional Medical Center | $2,675.00 | Approved |
| CLM-2026-026368 | 2026-02-16 | Meadow Medical Group | $278.00 | 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.